Nokea
A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
- A. Use pneumatic compression boots.
- B. Maintain bed rest for 24 to 48 hours.
- C. Assist with range-of-motion leg exercises.
- D. Elevate the knees with the knee gatch on the bed.
- E. Remove antiembolism stockings twice daily for assessment.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
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The nurse is teaching a client with gastroesophageal reflux disease (GERD) about lifestyle modifications. Which statement indicates understanding?
- A. I should eat large meals to avoid snacking.'
- B. I will sleep flat to relax my stomach.'
- C. I'll avoid lying down for 2 hours after eating.'
- D. I can drink orange juice with breakfast.'
Correct Answer: C
Rationale: Avoiding lying down for 2 hours after eating prevents acid reflux by keeping the stomach contents below the esophagus.
When performing chest percussion on a child, which of the following techniques should the nurse use?
- A. Firmly but gently striking the chest wall to make a popping sound.
- B. Gently striking the chest wall to make a slapping sound.
- C. Percussing over an area from the umbilicus to the clavicle.
- D. Placing a blanket between the nurse's hand and the child's chest.
Correct Answer: A
Rationale: Chest percussion involves firmly but gently striking the chest to produce a popping sound, mobilizing secretions without causing harm.
A client with a history of cirrhosis is admitted with hepatic encephalopathy. The nurse should include which of the following in the plan of care?
- A. Administer lactulose as prescribed.
- B. Encourage a high-protein diet.
- C. Restrict fluid intake.
- D. Administer sedatives for agitation.
Correct Answer: A
Rationale: Lactulose reduces ammonia levels in hepatic encephalopathy.
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see fi gure). The nurse should:
- A. Wear a powered air purifying respirator (PAPR) face shield.
- B. Use goggles that include the hairline.
- C. Change to a surgical mask.
- D. Proceed to suction the client’s tracheostomy.
Correct Answer: D
Rationale: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask. It is not necessary to wear a powered air purifying respirator face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.
A client with acute stress disorder is telling the nurse about the tornado that leveled his house and killed his wife and baby while he was out of town on business. He states, 'If only I'd been at home, I could have saved them.' Which of the following responses would be most appropriate?
- A. Don't blame yourself; you'll only feel worse.'
- B. It's not your fault; so stop feeling so guilty.'
- C. You might not have been at home.'
- D. You couldn't have prevented the tornado; it just happened.'
Correct Answer: D
Rationale: Acknowledging the uncontrollable nature of the tornado helps the client process guilt rationally, supporting coping with acute stress disorder.