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A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. In addition to notifying the physician, what other action should the nurse take immediately?
- A. Administer oxygen.
- B. Elevate the head of the bed 30 degrees.
- C. Administer a bolus of I.V. fluids.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Sudden vital sign changes post-gastrectomy suggest hypoxia or shock. Administering oxygen addresses potential respiratory compromise, a common postoperative issue, while awaiting physician guidance.
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A client has been admitted with acute renal failure. What should the nurse do? Select all that apply.
- A. Elevate the head of the bed 30 to 45 degrees.
- B. Take vital signs.
- C. Establish an I.V. access site.
- D. Call the admitting physician for orders.
- E. Contact the hemodialysis unit.
Correct Answer: B,C,D
Rationale: Taking vital signs, establishing IV access, and contacting the physician are immediate actions to assess and stabilize the client with acute renal failure.
The nurse in the intensive care unit is giving a report to the nurse in a cardiac step-down unit about a client who had coronary artery bypass surgery. Which of the following is the most effective way to assure essential information about the client is reported?
- A. Give the report face-to-face with both nurses in a quiet room.
- B. Audiotape the report for future reference and documentation.
- C. Use a printed checklist with information individualized for the client.
- D. Document essential transfer information in the client's electronic health record.
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is systematically communicated, reducing errors during handoff.
A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is inappropriate?
- A. Eating a diet high in fiber.
- B. Setting a regular time for elimination.
- C. Using an elevated toilet seat.
- D. Limiting fluid intake to 1,000 mL/day.
Correct Answer: D
Rationale: Limiting fluid intake to 1,000 mL/day is inappropriate, as adequate hydration is needed for bowel function. High-fiber diet, regular elimination times, and elevated toilet seats support bowel retraining.
What is the purpose of straining urine in a client with renal calculi?
- A. Detect blood.
- B. Identify stone composition.
- C. Measure urine volume.
- D. Prevent infection.
Correct Answer: B
Rationale: Straining urine captures stones for analysis to determine composition.
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.