Nokea
A client has a right total hip replacement. The client returns from surgery with an IV of 0.45% NaCl infusing into the left forearm at 100 cc/h. It is MOST important for the nurse to take which of the following actions?
- A. Massage the client's legs to increase circulation.
- B. Elevate the knee gatch to reduce stress on the suture line.
- C. Apply thigh-high TED hose to promote venous return.
- D. Decrease fluid intake to 1,200 cc to prevent circulatory overload.
Correct Answer: C
Rationale: use of antiembolic hose and/or sequential compression devices decreases venous stasis and reduces risk of thrombus formation
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A nurse is the first on the scene of a motor vehicle accident. The victim has sucking sounds with respirations at a chest wound site and tracheal deviation toward the uninjured side. Until others arrive, the priority nursing action would be to
- A. loosely cover the wound, preferably with a sterile dressing.
- B. place a sandbag over the wound.
- C. monitor chest wound drainage.
- D. place a firm, airtight, sterile dressing over the wound.
Correct Answer: A
Rationale: implementation, in an open pneumothorax, air enters the pleural cavity through an open wound; placing a sterile dressing loosely over the wound allows air to escape but not reenter the pleural space
A client had an aortic aneurysm resection two days ago. A complete blood count reveals a decreased red blood cell count. The nursing assessment is MOST likely to reveal which of the following?
- A. Fatigue, pallor, and exertional dyspnea.
- B. Nausea, vomiting, and diarrhea.
- C. Vertigo, dizziness, and shortness of breath.
- D. Malaise, flushing, and tachycardia.
Correct Answer: A
Rationale: these 'constitutional symptoms' are characteristic of most types of anemia and are predominantly the result of tissue hypoxia secondary to inadequate red blood cells
A client is admitted with a diagnosis of trigeminal neuralgia (tic douloureux) involving the maxillary branch of the affected nerve. When performing client teaching, it is MOST important for the nurse to include which of the following instructions?
- A. Report an increase in blurred vision.
- B. Eat soft, warm foods.
- C. Change positions slowly.
- D. Chew food on the affected side.
Correct Answer: B
Rationale: intense facial pain experienced along nerve tract is characteristic of this condition; nursing care should be directed toward preventing stimuli to the area and decreasing pain
The nurse is caring for a two-month-old infant. A pH probe test indicates that the infant has reflux. Which nursing action is MOST appropriate?
- A. Hold the next feeding.
- B. Teach the mother CPR.
- C. Maintain a normal feeding schedule.
- D. Elevate the head of the bed.
Correct Answer: D
Rationale: infant with reflux should be maintained in an upright position; head of the bed should be raised at a 30° angle
A 20-year-old woman calls the outpatient clinic to schedule her first Papanicolaou's smear. The nurse should instruct the client to
- A. avoid intercourse for 48 hours before the examination.
- B. avoid douching for 24 hours prior to her appointment.
- C. withhold all foods and fluids 12 hours before the appointment.
- D. save her first voided urine specimen the morning of her appointment.
Correct Answer: B
Rationale: douching would affect appearance of cells in vaginal smear, would make test inaccurate