Nokea
A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5°F (37.5°C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/µL. What should the nurse do first?
- A. Initiate an intake and output record.
- B. Place the client on bed rest.
- C. Place the client on contact isolation.
- D. Keep the client out of sunlight.
Correct Answer: B
Rationale: The client's symptoms (fatigue, bronze skin, dark urine, low hemoglobin, and RBC count) suggest hemolytic anemia, possibly due to an infectious or toxic exposure overseas. Placing the client on bed rest is the priority to reduce oxygen demand and prevent further hemolysis while diagnostic evaluation proceeds. Intake/output monitoring, isolation, and sunlight avoidance are not immediate priorities.
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A client with a history of heart failure has bilateral +4 edema of her right ankle that extends up to midcalf. She is sitting out of bed and has her legs in a dependent position. Which of the following goals is the priority?
- A. Decrease venous congestion
- B. Maintain normal respirations
- C. Maintain body temperature
- D. Prevent injury to lower extremities
Correct Answer: A
Rationale: Bilateral edema in heart failure results from increased venous pressure and congestion due to impaired cardiac output. The priority goal is to decrease venous congestion (e.g., by elevating legs or using compression) to reduce edema and improve circulation. Respirations, temperature, and injury prevention are secondary in this context.
Which assessment is critical for a client with a recent stroke?
- A. Swallowing ability.
- B. Blood glucose.
- C. Cholesterol levels.
- D. Joint mobility.
Correct Answer: A
Rationale: Assessing swallowing ability is critical to prevent aspiration in stroke patients.
The client with glaucoma is scheduled for a hip replacement. Which of the following orders would require clarification before the nurse carries it out?
- A. Administer morphine sulfate.
- B. Administer atropine sulfate.
- C. Teach deep-breathing exercises.
- D. Teach leg lifts and muscle-setting exercises.
Correct Answer: B
Rationale: Atropine sulfate can increase intraocular pressure, which is contraindicated in glaucoma. The nurse should clarify this order to ensure it is safe for the client.
The nurse is instructing the client about postsurgery activity following cataract surgery. What position should the nurse teach the client to use?
- A. Remain in a semi-Fowler's position.
- B. Position the feet higher than the body.
- C. Lie on the operative side.
- D. Place the head in a dependent position.
Correct Answer: A
Rationale: A semi-Fowler's position (head elevated 30-45 degrees) helps reduce intraocular pressure and swelling by promoting drainage and preventing fluid accumulation in the surgical eye.
The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.
- A. Determine that there will be a latex-safe environment for surgery.
- B. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing).
- C. Notify the health care providers at the surgery center.
- D. Wear a stainless steel medical alert bracelet into the surgical suite.
- E. Ask to have the surgery at a hospital.
Correct Answer: A,B,C
Rationale: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current.