Nokea
A client who is scheduled for an open cholecystectomy has a 20-pack-year history of smoking. For which postoperative complication is the client most at risk?
- A. Deep vein thrombosis.
- B. Atelectasis and pneumonia.
- C. Delayed wound healing.
- D. Prolonged immobility.
Correct Answer: B
Rationale: Smoking impairs lung function and ciliary clearance, increasing the risk of atelectasis and pneumonia post-surgery due to reduced lung expansion and mucus clearance.
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What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
- A. Compress the nares.
- B. Tilt the head back.
- C. Give the client tissues to collect the fluid.
- D. Administer an antihistamine for postnasal drip.
Correct Answer: C
Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.
The nurse is reviewing the postoperative orders (see chart) just written by a physician for a client with insulin-dependent diabetes who has returned to the surgery floor from the recovery. The client has pain of 5 on a scale of 1 to 10. The hand-off report from the nurse in the recovery room indicated that the vital signs have been stable for the last 30 minutes. After obtaining the client's glucose level, the nurse should do which of the following first?
- A. Administer the morphine.
- B. Contact the physician to report the glucose level and rewrite the insulin order.
- C. Administer oxygen per nasal cannula at 2 L/minute.
- D. Take the vital signs.
Correct Answer: B
Rationale: The glucose level must be assessed to determine if insulin is safe to administer, as hypoglycemia could worsen with insulin. Contacting the physician ensures appropriate insulin dosing.
Which of the following is an expected outcome when a client is receiving an I.V. administration of furosemide?
- A. Increased blood pressure.
- B. Increased urine output.
- C. Decreased pain.
- D. Decreased premature ventricular contractions.
Correct Answer: B
Rationale: Furosemide, a loop diuretic, promotes diuresis, increasing urine output to reduce fluid overload in conditions like heart failure or post-MI.
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.
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.