Nokea
A client with peripheral vascular disease has bypass surgery. The primary goal of the plan of care after surgery is to:
- A. Maintain circulation
- B. Prevent infection
- C. Relieve pain
- D. Provide education
Correct Answer: A
Rationale: The primary goal post-bypass surgery for PVD is to maintain circulation, ensuring graft patency and adequate blood flow to the extremity to prevent ischemia or graft failure. Infection prevention, pain relief, and education are important but secondary to circulation.
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The nurse is to administer flumazenil (Mazicon) I.V. for reversal of sedation. Which of the following interventions should be included in the care plan? Select all that apply.
- A. Administer the medication as a 2-mg bolus.
- B. Give the medication undiluted in incremental doses.
- C. Be alert for shivering and hypotension.
- D. Use only a free-flowing I.V. line in a large vein.
- E. Monitor the client's level of consciousness.
Correct Answer: B,C,D,E
Rationale: Flumazenil is given undiluted in incremental doses (B), via a free-flowing IV line (D), with monitoring for side effects like shivering and hypotension (C) and level of consciousness (E). A 2-mg bolus (A) is incorrect, as flumazenil is titrated in smaller doses.
Which of the following statements would indicate to the nurse that the client who has undergone repair of her nasal septum has understood the discharge instructions?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Taking stool softeners and modifying the diet to prevent constipation avoids straining (Valsalva's maneuver), which could cause bleeding or complications post-nasal surgery.
When comparing the hematocrit levels of a postoperative client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC count and hemoglobin value remained within 10 mg/dL and 11.9 g/dL, respectively. The nurse should:
- A. Check the dressing and drains for frank bleeding.
- B. Call the physician.
- C. Continue to monitor vital signs.
- D. Start oxygen at 2 L/minute per nasal cannula.
Correct Answer: C
Rationale: A slight decrease in hematocrit (36% to 34%) on postoperative day 3, with stable RBC count and hemoglobin, is likely due to hemodilution from fluid administration rather than active bleeding. The nurse should continue to monitor vital signs and hematologic parameters. Checking for bleeding is unnecessary without signs of hemorrhage, calling the physician is premature, and oxygen is not indicated.
Metoclopramide (Reglan) is ordered as a premedication for a client about to undergo a gastroduodenoscopy. The nurse expects which of the following as the primary therapeutic effect?
- A. Increased gastric pH.
- B. Increased gastric emptying.
- C. Reduced anxiety.
- D. Inhibited respiratory secretions.
Correct Answer: B
Rationale: Metoclopramide promotes gastric emptying, which is beneficial before gastroduodenoscopy to reduce the risk of aspiration and improve visualization.
The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages?
- A. 20%
- B. 40%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: Claudication typically occurs when arterial occlusion reaches approximately 50%, significantly reducing blood flow to muscles during activity. This causes ischemia and pain, which is relieved by rest when oxygen demand decreases. Complete (100%) occlusion would cause rest pain or tissue necrosis, not just claudication.