Nokea
A client is 4 hours post-op left carotid endarterectomy. Which assessment finding would cause the nurse the most concern?
- A. Temperature 99.4°F, heart rate 110, respiratory rate 24
- B. Drowsiness, urinary output of 50 mL the past hour, 1 cm blood drainage noted on surgical dressing
- C. BP 120/60, lethargic, right-sided weakness
- D. Alert and oriented, BP 168/96, heart rate 70
Correct Answer: C
Rationale: Right-sided weakness post-left carotid endarterectomy suggests a neurological deficit, possibly from stroke or hematoma, requiring immediate intervention.
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The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glascow coma scale.
Correct Answer: A
Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction?
- A. 16-year-old female with scoliosis
- B. 12-year-old male with a fractured femur
- C. 10-year-old male with sarcoma
- D. 6-year-old male with osteomylitis
Correct Answer: B
Rationale: A 12-year-old male with a similar condition provides age-appropriate companionship and shared care needs.
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the doctor
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious process (e.g., herpes), so reporting it to the doctor is the most appropriate initial action.
An operating room nurse just received a client scheduled for a laparoscopic cholecystectomy, but discovers the consent form has not been signed. What is the most appropriate action?
- A. bring the client a new consent form and have him sign it right away
- B. call the surgeon and ask how she would like to proceed
- C. inform the nursing manager there is no signed consent form
- D. ask the unit manager if the surgery can be rescheduled for later in the day
Correct Answer: B
Rationale: Missing consent requires notifying the surgeon to ensure the client is informed and consents before proceeding, adhering to legal and ethical standards.
A client is admitted with suspected abdominal aortic aneurysm (AAA). A common complaint of the client with an abdominal aortic aneurysm is:
- A. Loss of sensation in the lower extremities
- B. Back pain that lessens when standing
- C. Decreased urinary output
- D. Pulsations in the periumbilical area
Correct Answer: D
Rationale: A pulsatile mass in the periumbilical area is a classic symptom of an abdominal aortic aneurysm due to the expanding aorta.