Nokea
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
- A. Auscultate the abdomen for bowel sound activity.
- B. Bring additional sterile dressing supplies to the room.
- C. Obtain a sample of the drainage to send to the laboratory.
- D. Prepare the client to return to the operating room.
Correct Answer: D
Rationale: Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.
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The healthcare provider prescribes penicillin 200,000 units IM for a client with pneumonia. The available vial is labeled, 'Penicillin 500,000 units/mL.' How many mL should the nurse administer to this client?
- A. 0.4
Correct Answer: A
Rationale: To calculate: 200,000 units / 500,000 units/mL = 0.4 mL. The nurse should administer 0.4 mL.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Avoid wearing tight fitting clothes.
- B. Minimize intake of spicy foods.
- C. Begin a smoking cessation program.
- D. Remain upright following meals.
Correct Answer: D
Rationale: Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter, minimizing reflux episodes.
Initial Assessment
Orders
A 34-year-old male client presents to the emergency department (ED) for an acute asthma attack which began after jogging through a local park. The client is able to answer questions, pausing every few words to catch his breath. The client reports using a rescue Inhaler three times, but he just couldn't catch his breath. The client reports that symptoms seem worse when outdoors and when exercising and that episodes like this make him extremely nervous. The client reports that it has been a couple of months since he had an asthma attack, and he came to the ED today because he noticed that his inhaler was expired and was worried the medication was not working.
The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, what action(s) should the nurse anticipate? Select all that apply.
- A. Provide client teaching
- B. Apply oxygen via nasal cannula.
- C. Ask the client for a list of current medications.
- D. Place the client in Trendelenburg position.
- E. Notify the healthcare provider of the client's need for intubation.
- F. Administer medications as ordered.
Correct Answer: A,B,C,F
Rationale: Client education, oxygen therapy, obtaining medication history, and administering ordered medications address the client's asthma exacerbation and promote effective management.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
- A. Sip fluids with each meal.
- B. Chew slowly and thoroughly.
- C. Reduce intake of fatty foods.
- D. Eat small frequent meals.
Correct Answer: D
Rationale: Eating small frequent meals is crucial after gastric bypass surgery to prevent complications like dumping syndrome and manage portion sizes effectively.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Palpitations and shortness of breath.
- B. Bradycardia and constipation.
- C. Muscle cramping and dry, flushed skin.
- D. Lethargy and lack of appetite.
Correct Answer: A
Rationale: Palpitations and shortness of breath are symptoms of thyrotoxicosis, indicating excessive thyroid hormone levels, which could result from an overdose of levothyroxine.