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A client is vomiting. Which of the following actions should the nurse take first?
- A. Provide the client with an emesis basin
- B. Notify housekeeping
- C. Prevent the client from aspirating
- D. Administer an antiemetic to the client
Correct Answer: C
Rationale: The correct action for the nurse to take first is to prevent the client from aspirating. Aspiration is a serious risk when a client is vomiting as it can lead to respiratory complications. The nurse should position the client on their side to prevent aspiration of vomitus into the airway. This immediate action takes priority over providing an emesis basin, notifying housekeeping, or administering an antiemetic, which do not address the urgent need to prevent aspiration.
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A 56-year-old patient comes to the walk-in clinic for scant rectal bleeding and intermittent diarrhea and constipation for the past several months. There is a history of polyps and a family history for colorectal cancer. While you are trying to teach about colonoscopy, the patient becomes angry and threatens to leave. What is the priority diagnosis?
- A. Diarrhea/Constipation related to altered bowel patterns.
- B. Knowledge Deficit related to disease process and diagnostic procedure.
- C. Risk for Fluid Volume Deficit related to rectal bleeding and diarrhea.
- D. Anxiety related to unknown outcomes and perceived threats to body integrity.
Correct Answer: D
Rationale: The patient's anger and threat to leave indicate significant anxiety, which must be addressed before proceeding with education or further assessment.
Seven tasks required for daily living with chronic illness have been identified. From Table 5-4, select at least one of these tasks that would specifically apply to the following common chronic conditions in older adults.
- A. Diabetes mellitus
- B. Visual impairment
- C. Heart disease
- D. Hearing impairment
Correct Answer: A
Rationale: Each chronic condition requires specific daily living tasks: Diabetes involves monitoring blood sugar; visual impairment may require adaptive techniques; heart disease necessitates lifestyle modifications; hearing impairment might involve using assistive devices.
What does progression of patients through various phases of care in a postanesthesia care unit (PACU) primarily depend on?
- A. Condition of patient
- B. Type of anesthesia used
- C. Preference of surgeon
- D. Type of surgical procedure
Correct Answer: A
Rationale: Patient condition dictates the progression through PACU phases, ensuring appropriate care levels.
Treatment of the patient with appendicitis includes
- A. Transfusion to replace blood loss.
- B. Bowel preparation for cleansing.
- C. Surgical removal of appendix.
- D. Medications to lower pH within stomach.
Correct Answer: C
Rationale: Surgical removal of the appendix is the definitive treatment for appendicitis.
A 44-year-old male client had abdominal surgery this morning. The nurse noticed a small amount of bloody drainage on the client's surgical dressing. This type of drainage is:
- A. serosanguineous.
- B. purulent.
- C. sanguineous.
- D. catarrhal.
Correct Answer: C
Rationale: Drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Purulent drainage usually indicates infection. This drainage should not be seen initially from a surgical incision. An incision with a Penrose drain may be expected to have a moderate amount of serosanguineous drainage in the first 24 hours, but in general drainage from a surgical incision is initially sanguineous (red), proceeding to serosanguineous (pink), then to serous (straw-colored). Catarrhal is a type of exudate seen in upper respiratory infections, not in surgical incisions.