Nokea
A client is to be discharged from same-day surgery 7 hours after his inguinal hernia repair. Which of the following indicates this client is ready to be discharged?
- A. The client voids 500 mL of urine.
- B. The client tolerates eating a hamburger.
- C. The client is pain-free.
- D. The client walks in the hallway unassisted.
Correct Answer: A
Rationale: Voiding 500 mL indicates normal bladder function, a key discharge criterion after hernia repair, ensuring no urinary retention from anesthesia or surgery.
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A nurse is obtaining consent for a bone marrow aspiration. What should the nurse do? Select all that apply.
- A. Witness the client signing the consent form.
- B. Evaluate that the client understands the procedure.
- C. Explain the risks of the procedure to the client.
- D. Verify that the client is signing the consent form of his own free will.
- E. Determine that the client understands postprocedure care.
Correct Answer: A,B,D,E
Rationale: The nurse's role in obtaining consent includes witnessing the signature, ensuring the client understands the procedure and postprocedure care, and verifying voluntary consent. Explaining risks is typically the physician's responsibility.
A client with vasospastic disorder (Raynaud's phenomenon) is scheduled for sympathectomy. This surgery is performed:
- A. In the early stages of the disease to prevent further circulatory disturbances
- B. When the disease is controlled by medication
- C. When the client is unable to control stress-related vasospasm
- D. When all other treatment alternatives have failed
Correct Answer: D
Rationale: Sympathectomy, which severs sympathetic nerves to reduce vasospasm, is a last-resort treatment for Raynaud's when all other options (medications, lifestyle changes) fail. It is not performed early, when controlled, or solely for stress-related vasospasm.
A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm, respiration rate of 16/minute, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature of 100.4°F (38°C). What should the nurse do first?
- A. Obtain a culture of the incision.
- B. Notify the surgeon to obtain an antibiotic order.
- C. Adjust the client to a sitting position to take deep breaths.
- D. Administer an antipyretic medication.
Correct Answer: C
Rationale: A pulse oximetry of 91 indicates mild hypoxemia. Adjusting to a sitting position and encouraging deep breaths improves oxygenation, addressing the most immediate concern.
The client with diabetes mellitus says, 'If I could just avoid what you call carbohydrates in my diet, I guess I would be okay.' The nurse should base the response to this comment on the knowledge that diabetes affects metabolism of which of the following?
- A. Carbohydrates only.
- B. Fats and carbohydrates only.
- C. Protein and carbohydrates only.
- D. Proteins, fats, and carbohydrates.
Correct Answer: D
Rationale: Diabetes affects the metabolism of carbohydrates, proteins, and fats due to insulin's role in regulating all three macronutrients.
The teaching plan for the client with rheumatoid arthritis includes rest promotion. Which of the following would the nurse expect to instruct the client to avoid during rest periods?
- A. Proper body alignment.
- B. Elevating the part.
- C. Prone lying positions.
- D. Positions of flexion.
Correct Answer: D
Rationale: Positions of flexion can exacerbate joint stiffness and deformity in rheumatoid arthritis. Proper alignment, elevation, and prone positions (if comfortable) support joint health.