Nokea
A client with a recent total knee replacement reports swelling in the operative leg. Which nursing action is most appropriate?
- A. Elevate the leg on two pillows.
- B. Apply a warm compress to the knee.
- C. Encourage immediate ambulation.
- D. Notify the healthcare provider.
Correct Answer: A
Rationale: Elevating the leg reduces swelling by promoting venous return, a standard post-surgical intervention.
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The physician orders Morphine Sulfate 2-4 mg IV push every 2 hours prn pain for a client who has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing change with packing at 10 AM, the nurse assesses the client's pain level as 1 on a scale of 0 = no pain to 10 = the worst pain. The client is awake and oriented and vital signs are within normal limits. The nurse reviews the pain medication record (see chart). The nurse should:
- A. Perform the dressing change.
- B. Administer Morphine 2 mg IV before the dressing change.
- C. Administer Morphine 4 mg IV after the dressing change.
- D. Call the physician for a new medication order.
Correct Answer: A
Rationale: With a pain level of 1, the client does not require morphine (prn order). Performing the dressing change is appropriate, as the pain is minimal and manageable.
Which of the following individuals are at risk for acquiring acute lymphocytic leukemia (ALL)? The client who is:
- A. 20 to 30 years.
- B. 40 to 50 years.
- C. 60 to 70 years.
- D. None of the above
Correct Answer: A
Rationale: ALL is most common in children and young adults, with a peak incidence in those aged 20–30 years. Older adults (40–70 years) are more likely to develop AML or CLL.
A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confirmation of placement. The client becomes diaphoretic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for:
- A. An air embolus.
- B. A pneumothorax.
- C. A pulmonary embolus.
- D. A myocardial infarction.
Correct Answer: B
Rationale: Absent breath sounds, chest pain, and tachycardia post-catheter insertion suggest a pneumothorax, a known complication of subclavian catheter placement, requiring urgent assessment.
Before undergoing a transsphenoidal hypophysectomy, the client asks the nurse how the surgeon will close the incision made in the dura. The nurse should respond based on the knowledge that:
- A. Dissolvable sutures are used to close the dura.
- B. Nasal packing provides pressure until normal wound healing occurs.
- C. A patch is made with a piece of fascia.
- D. A synthetic mesh is placed to facilitate healing.
Correct Answer: C
Rationale: A fascial patch is commonly used to repair the dura during transsphenoidal hypophysectomy to prevent CSF leaks.
The nurse is providing discharge instructions to a client who underwent left eye cataract surgery with a lens implant. Which statement by the client would indicate a correct understanding of the teaching?
- A. I should avoid getting water in the eye for 3 to 7 days after surgery.'
- B. It is okay for me to resume normal chores such as vacuuming.'
- C. It is okay for me to have green or yellow, thick drainage from the eye.'
- D. I may take aspirin for any pain I may experience.'
Correct Answer: A
Rationale: Avoiding water in the eye for 3-7 days post-cataract surgery prevents infection. Heavy chores like vacuuming, abnormal drainage, and aspirin use (which risks bleeding) are contraindicated.