Nokea
A client who has had an above-the-knee amputation is to have a dressing change 45 minutes after arriving in the postanesthesia recovery unit. The nurse should:
- A. Elevate the stump.
- B. Reinforce the dressing.
- C. Call the surgeon.
- D. Draw a mark around the site.
Correct Answer: C
Rationale: Excessive bleeding requires the surgeon's evaluation to prevent complications.
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Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
- A. Sore throat.
- B. Painful, excessive menstruation.
- C. Constipation.
- D. Increased urine output.
Correct Answer: A
Rationale: Propylthiouracil (PTU) can cause agranulocytosis, a serious condition involving a low white blood cell count, which may present as a sore throat or fever. This requires immediate reporting. The other symptoms are not typically associated with PTU side effects.
After the nurse has administered droperidol (Inapsine), care is taken to move the client slowly based on the knowledge of droperidol's effect on the:
- A. Central nervous system.
- B. Respiratory system.
- C. Cardiovascular system.
- D. Psychoneurologic system.
Correct Answer: C
Rationale: Droperidol can cause hypotension and orthostatic changes, affecting the cardiovascular system. Slow movement prevents dizziness or falls due to these effects.
A client who has been treated for chronic open-angle glaucoma (COAG) for 5 years asks the nurse, 'How does glaucoma damage my eyesight?' The nurse's reply should be based on the knowledge that COAG:
- A. Results from chronic eye inflammation.
- B. Causes increased intraocular pressure.
- C. Leads to detachment of the retina.
- D. Is caused by decreased blood flow to the retina.
Correct Answer: B
Rationale: Chronic open-angle glaucoma causes increased intraocular pressure, which damages the optic nerve over time, leading to vision loss.
Which of the following is significant data to gather from a client who has been diagnosed with pneumonia? Select all that apply.
- A. Quality of breath sounds.
- B. Presence of bowel sounds.
- C. Occurence of chest pain.
- D. Amount of peripheral edema.
- E. Color of nail beds.
Correct Answer: A,C,E
Rationale: Breath sounds (A) indicate lung involvement. Chest pain (C) may signal pleurisy or complications. Nail bed color (E) reflects oxygenation. Bowel sounds and peripheral edema are less relevant to pneumonia assessment.
The nurse is aware that a 65-year-old widower whose only son is 500 miles away is at higher risk for psychosocial distress because the client:
- A. Has been successful in dealing with stress all his life.
- B. Does not have to deal with other stressors right now.
- C. Is able to use denial as a coping mechanism.
- D. Perceives he has minimal social support.
Correct Answer: D
Rationale: Minimal social support, due to being widowed and geographically isolated from his son, increases the risk of psychosocial distress in this cancer client.