Nokea
A client with peripheral vascular disease returns to the surgical care unit after having femoral-popliteal bypass grafting. Indicate in which order the nurse should conduct assessment of this client.
- A. Postoperative pain
- B. Peripheral pulses
- C. Urine output
- D. Incision site
Correct Answer: B,A,C,D
Rationale: The correct order is: 1) Peripheral pulses (to confirm graft patency and limb perfusion, the highest priority); 2) Postoperative pain (to assess comfort and detect complications); 3) Urine output (to monitor renal perfusion and fluid status); 4) Incision site (to check for infection or bleeding, less urgent). This prioritizes circulation and vital organ function.
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A client with cancer develops superior vena cava syndrome (SVCS). Which of the following symptoms should the nurse assess for?
- A. Facial swelling and dyspnea.
- B. Lower extremity edema.
- C. Abdominal distension.
- D. Flank pain.
Correct Answer: A
Rationale: SVCS obstructs venous return, causing facial swelling and dyspnea due to compression of the superior vena cava, which the nurse should prioritize in assessment.
An alert and oriented elderly client is admitted to the hospital for treatment of cellulitis of the left shoulder after an arthroscopy. Which fall prevention strategy is most appropriate for this client?
- A. Use a nightlight in the bathroom.
- B. Keep all four side rails up at all times.
- C. Place the client in a room with a camera monitor.
- D. Place the client in a room with a camera monitor.
Correct Answer: A
Rationale: A nightlight reduces fall risk by improving visibility during nighttime bathroom trips, suitable for an alert client. Four side rails are a restraint and unsafe.
The nurse in the intensive care unit is giving a report to the nurse in the post-surgical unit about a client who had a gastrectomy. The most effective way to assure essential information about the client is reported is to:
- A. Give the report face-to-face with both nurses in a quiet room.
- B. Audiotape the report for future reference and documentation.
- C. Use a printed checklist with information individualized for the client.
- D. Document essential transfer information in the client's electronic health record.
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is communicated consistently and reduces the risk of omissions during the report.
A client tells the nurse on admission that she is uneasy about having to leave her children with a relative while being in the hospital for surgery. The most appropriate action by the nurse is to do which of the following?
- A. Reassure the client that her children will be fine and she should stop worrying.
- B. Contact the relative to determine their capacity to be an adequate care provider.
- C. Encourage the client to call the children to make sure they are doing well.
- D. Gather more information about the client's feelings about the childcare arrangements.
Correct Answer: D
Rationale: The health history is conducted to ascertain a client's state of wellness or illness. A personal dialogue between a client and a nurse is conducted to obtain information. To achieve a relationship of mutual trust and respect, the nurse must have the ability to communicate a sincere interest in the client. The therapeutic communication must be adapted to the responses, problems, and needs of the client. Reassurance and the remaining options do not demonstrate that the nurse is genuinely interested in the client's needs. (CN: Psychosocial adaptation; CL: Synthesize)
The nurse is taking care of a client with a spinal cord injury. The extent of the client’s injury is shown below. Which of the following findings is expected when assessing this client?
- A. Inability to move his arms
- B. Loss of sensation in his hands and fingers.
- C. Dysfunction of bowel and bladder.
- D. Difficulty breathing.
Correct Answer: C
Rationale: This client has a spinal cord injury of the sacral region of the spinal cord and will have bladder and bowel dysfunction, as well as loss of sensation and muscle control below the injury. The other options are true of a client who has quadriplegia.