Nokea
A client who has undergone a subtotal thyroidectomy is subject to complications in the first 48 hours after surgery. The nurse should obtain and keep at the bedside equipment to:
- A. Begin total parenteral nutrition.
- B. Start a cutdown infusion.
- C. Administer tube feedings.
- D. Perform a tracheotomy.
Correct Answer: D
Rationale: Tracheotomy equipment is essential due to the risk of airway obstruction from swelling or hemorrhage post-thyroidectomy.
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The nurse is reviewing a client's chart and notes a discrepancy in the TPN order. Which action should the nurse take first?
- A. Adjust the infusion rate to match the order.
- B. Contact the prescribing physician for clarification.
- C. Continue the current infusion rate.
- D. Document the discrepancy in the client's chart.
Correct Answer: B
Rationale: Contacting the prescribing physician for clarification is the first action to resolve a discrepancy in a TPN order, ensuring safety and accuracy. Adjusting the rate, continuing the current rate, or documenting without clarification risks errors. CN: Safety and infection control; CL: Synthesize
Following abdominal surgery, a client refuses to deep breathe and cough every 2 hours as ordered. The nurse should do which of the following first?
- A. Ask the client's wife to assist with the daily fluid intake to at least 2,500 mL.
- B. Respect the client's wishes and turn the client from side-to-side more frequently.
- C. Assess the client's reasons for refusing to deep breathe and cough.
- D. Explain the risks of not expanding the lungs and why the exercise is important.
Correct Answer: C
Rationale: Assessing the client's reasons for refusal identifies barriers (e.g., pain, fear), allowing tailored interventions to encourage compliance with deep-breathing exercises.
A client post-cystoscopy is discharged. The nurse should instruct to:
- A. Resume normal activity.
- B. Avoid fluids for 24 hours.
- C. Expect blue urine.
- D. Take antibiotics for a week.
Correct Answer: A
Rationale: Normal activity can resume post-cystoscopy unless complications arise.
The nurse is assessing a client with hepatitis and notices that the AST and ALT levels have increased. Which of the following statements by the client requires further instruction by the nurse?
- A. I require increased periods of rest.
- B. I follow a low-fat, high carbohydrate diet.
- C. I eat dry toast to relieve my nausea.
- D. I take acetaminophen (Tylenol) for arthritis pain.
Correct Answer: D
Rationale: Acetaminophen (D) is hepatotoxic and should be avoided in hepatitis due to increased liver enzyme levels. Rest (A), a low-fat, high-carbohydrate diet (B), and dry toast for nausea (C) are appropriate.
The nurse is developing a plan of care for a client with Crohn's disease who is receiving total parenteral nutrition (TPN). Which of the following interventions should the nurse include? Select all that apply.
- A. Monitoring vital signs once a shift.
- B. Weighing the client daily.
- C. Changing the central venous line dressing daily.
- D. Monitoring the I.V. infusion rate hourly.
- E. Taping all I.V. tubing connections securely.
Correct Answer: B,C,D,E
Rationale: For a client on TPN, daily weight monitoring (B), daily dressing changes (C), hourly infusion rate checks (D), and securing tubing connections (E) are critical to prevent complications like infection or fluid imbalance. Vital signs once a shift (A) is insufficient; more frequent monitoring is needed. CN: Pharmacological and parenteral therapies; CL: Create