Nokea
A client with stage II ovarian cancer undergoes a total abdominal hysterectomy and bilateral salpingo- oopherectomy with tumor secretion, omentectomy, appendectomy, and lymphadenopathy. During the second postoperative day, which of the following assessment findings would raise concern in the nurse?
- A. Abdominal pain
- B. Serous drainage from the incision
- C. Hypoactive bowel sounds
- D. Shallow breathing and increasing lethargy
Correct Answer: D
Rationale: Shallow breathing and increasing lethargy are concerning assessment findings postoperatively as they can be indicative of respiratory complications such as atelectasis, pneumonia, or pulmonary embolism. These conditions can be life-threatening and require prompt medical attention. It is essential for the nurse to monitor the client closely for any signs of respiratory distress and intervene immediately if these symptoms are present. Abdominal pain, serous drainage from the incision, and hypoactive bowel sounds are common findings after abdominal surgery and are expected in the early postoperative period.
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Which of the ff nursing interventions may reduce hemostasis and decrease the potential for thrombophlebitis for a client with a neurologic disorder?
- A. Remove and reapply elastic stockings
- B. Keep extremities at neutral position
- C. Change the clients position
- D. Use a flotation mattress NEUROMUSCULAR DISORDERS
Correct Answer: B
Rationale: Keeping the extremities at a neutral position for a client with a neurologic disorder can help reduce hemostasis and decrease the potential for thrombophlebitis. This positioning helps maintain proper blood flow and prevents excessive pressure on the veins, which can lead to blood clots. Removing and reapplying elastic stockings, changing the client's position, and using a flotation mattress may have their own benefits, but in this case, keeping the extremities at a neutral position is the most direct and effective intervention to address the issue of hemostasis and thrombophlebitis for a client with a neurologic disorder.
During thoracentesis, which of the following nursing intervention will be most crucial?
- A. Place patient in a quiet and cool room
- B. Maintain strict aseptic technique
- C. Advice patient to sit perfectly still during needle insertion until it has been withdrawn from the chest
- D. Apply pressure over the puncture site as soon as the needle is withdrawn
Correct Answer: B
Rationale: Maintaining strict aseptic technique during thoracentesis is the most crucial nursing intervention. Thoracentesis is a procedure where a needle is inserted into the pleural space to obtain a sample of fluid for diagnostic purposes or to drain excess fluid for therapeutic relief. It is essential to prevent the introduction of pathogens or contaminants into the pleural space, as this can lead to serious complications such as infection. By following strict aseptic technique, the risk of complications can be minimized, ensuring the safety and well-being of the patient undergoing the procedure.
Which of the ff is the main reason why older clients with AIDS need more care than their younger counterparts?
- A. Because the older clients lack balanced diet and activity
- B. Because older clients lack knowledge about disorders
- C. Because older clients have a faster progression of disease
- D. Because older clients do not generally adhere to a therapy
Correct Answer: C
Rationale: The main reason why older clients with AIDS need more care than their younger counterparts is because older clients have a faster progression of the disease. As a person ages, their immune system tends to weaken, making them more vulnerable to infections and complications from diseases like AIDS. Older individuals may have decreased immune function and lower resilience when combating HIV-related complications compared to younger clients. This faster disease progression necessitates more frequent monitoring, specialized care, and management strategies tailored to the specific needs of older patients with AIDS. Therefore, older clients with AIDS require more support, medical attention, and comprehensive care to address their complex health needs effectively.
An adolescent girl calls the nurse at the clinic because she had unprotected sex the night before and does not want to be pregnant. What should the nurse explain to the girl?
- A. It is too late to prevent an unwanted pregnancy
- B. An abortion may be the best option if she is pregnant
- C. Norplant can be administered to prevent pregnancy for up to 5 years
- D. Postcoital contraception is available to prevent implantation
Correct Answer: D
Rationale: In this scenario, the most appropriate option for the nurse to explain to the adolescent girl is postcoital contraception, also known as emergency contraception or the morning-after pill. Postcoital contraception is a method used to prevent pregnancy after unprotected sex or contraceptive failure. It works by preventing or delaying ovulation, inhibiting fertilization, or preventing implantation of a fertilized egg in the uterus.
Which medication is most likely included in post-operative care of a child with repair of bladder exstrophy?
- A. Lasix
- B. Mannitol
- C. Meperidine
- D. Oxybutynin
Correct Answer: D
Rationale: Oxybutynin helps control bladder spasms and improves comfort after urinary reconstructive surgery.