Nokea
A client has an emergency embolectomy for an embolus in the femoral artery. After the client returns from the recovery room, in what order, from first to last, should the nurse provide care?
- A. Administer pain medication
- B. Draw blood for laboratory studies
- C. Regulate the I.V. infusion
- D. Monitor the pulses
- E. Inspect the dressing
Correct Answer: D,C,A,B,E
Rationale: Order: 1) Monitor pulses (ensure arterial patency post-embolectomy); 2) Regulate I.V. infusion (maintain hydration/perfusion); 3) Administer pain medication (manage comfort); 4) Draw blood for labs (monitor coagulation); 5) Inspect dressing (check for bleeding/infection).
You may also like to solve these questions
The nurse should include which of the following instructions in the teaching plan for a client with chronic sinusitis?
- A. Avoid the use of caffeinated beverages.
- B. Perform postural drainage every day.
- C. Take hot showers twice daily.
- D. Report a temperature of 102°F (38.9°C) or higher.
Correct Answer: C,D
Rationale: Hot showers help moisten nasal passages and promote sinus drainage, relieving symptoms of chronic sinusitis. Reporting a high fever is critical as it may indicate a worsening infection requiring medical attention. Caffeine restriction is not typically necessary. Postural drainage is more relevant for lung conditions like bronchiectasis.
What should the nurse include in the care plan for a client with dysphagia?
- A. Offer thin liquids.
- B. Use a chin-tuck maneuver.
- C. Provide a low-fiber diet.
- D. Encourage rapid eating.
Correct Answer: B
Rationale: The chin-tuck maneuver reduces aspiration risk in clients with dysphagia.
When performing external chest compressions on an adult during cardiopulmonary resuscitation (CPR), the rescuer should depress the sternum:
- A. 0.5 to 1 inch.
- B. 1 to 1.5 inches.
- C. 1.5 to 2 inches.
- D. 2 to 2.5 inches.
Correct Answer: C
Rationale: Depressing the sternum 1.5 to 2 inches ensures adequate compression depth for effective CPR in adults, per guidelines.
A client has chest pain rated at 8 on a 10 point visual analog scale. The 12-lead electrocardiogram reveals ST elevation in the inferior leads and Troponin levels are elevated. What is the highest priority for nursing management of this client at this time?
- A. Monitor daily weights and urine output.
- B. Permit unrestricted visitation by family and friends.
- C. Provide client education on medications and diet.
- D. Reduce pain and myocardial oxygen demand.
Correct Answer: D
Rationale: The client is experiencing an acute myocardial infarction, indicated by ST elevation and elevated troponin. Reducing pain and myocardial oxygen demand is critical to minimize further cardiac damage.
When teaching the client with myocardial infarction (MI), the nurse explains that the pain associated with MI is caused by:
- A. Left ventricular overload.
- B. Impending circulatory collapse.
- C. Extracellular electrolyte imbalances.
- D. Insufficient oxygen reaching the heart muscle.
Correct Answer: D
Rationale: MI pain results from myocardial ischemia due to insufficient oxygen delivery to the heart muscle, caused by coronary artery occlusion.