Nokea
A male client has returned to the Unit following a left femoral popliteal bypass graft. Six hours later, the client's dorsalis pedis pulse cannot be palpated and his foot is cool and dusky. The nurse should:
- A. continue to monitor the foot.
- B. immediately notify the physician.
- C. notify the head nurse.
- D. assure the client that his foot is fine.
Correct Answer: B
Rationale: The client is losing the blood supply to his left foot. Continuing to monitor will not restore the blood supply to the foot. The physician should be notified immediately because the client is losing the blood supply to his left foot and is in danger of losing his foot and/or his leg. It is the responsibility of the nurse caring for the client to notify the physician, not the head nurse. This would be giving the client false assurances, which is unethical, demeaning, and could have legal consequences.
You may also like to solve these questions
Jane, an obese hypertensive homemaker, complains of continual hunger and lack of energy. What nursing measure would be most helpful?
- A. Giving her a list of low-calorie foods
- B. Discussing the importance of eating breakfast
- C. Recommending a strict vegetarian diet
- D. Suggesting vitamin supplements
Correct Answer: B
Rationale: Eating breakfast helps regulate metabolism and energy levels throughout the day, reducing hunger and fatigue.
A 44-year-old female client had an emergency cholecystectomy three days ago for a ruptured gallbladder. The client has severe abdominal pain, abdominal rigidity, distension, increased temperature, tachycardia and an elevated white blood count (WBC). The client has probably developed:
- A. gastritis.
- B. evisceration.
- C. peritonitis.
- D. a pulmonary embolism.
Correct Answer: C
Rationale: Assessment findings of gastritis would reveal anorexia, nausea and vomiting, epigastric fullness and tenderness, and discomfort. Evisceration is the extrusion of abdominal viscera as a result of trauma or sutures failing in a surgical incision. Peritonitis, inflammation of the peritoneum, can occur when an abdominal organ, such as the gallbladder, perforates and leaks blood and fluid into the abdominal cavity, which causes infection and irritation. Assessment findings of a pulmonary embolism would reveal severe substernal chest pain, tachycardia, tachypnea, shortness of breath, anxiety or panic, and wheezing and coughing, often accompanied by blood-tinged sputum.
What is your priority intervention for this patient?
- A. Transportation arrangements to a safe house
- B. Referral to a counselor
- C. Advise about contacting the police
- D. Follow-up appointment for injuries
Correct Answer: A
Rationale: Ensuring the patient's safety by arranging transportation to a safe house is the top priority.
While providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort, which of the following desired effects of medications should the nurse identify as most important for the client's recovery?
- A. It decreases the client's level of anxiety.
- B. It facilitates the client's deep breathing.
- C. It enhances the client's ability to sleep.
- D. It reduces the client's blood pressure.
Correct Answer: B
Rationale: The correct answer is B because facilitating the client's deep breathing is crucial post-CABG surgery to prevent complications such as atelectasis and pneumonia. Deep breathing helps improve lung expansion and oxygenation, promoting healing and preventing respiratory issues.
A: While decreasing anxiety is important for overall well-being, it is not directly related to the client's recovery post-CABG surgery.
C: Enhancing sleep is beneficial for healing, but it is not as critical as ensuring proper respiratory function in the immediate postoperative period.
D: While reducing blood pressure may be desirable in some cases, it is not the most important effect to focus on post-CABG surgery; maintaining adequate oxygenation through deep breathing takes precedence.
Which of the following would be appropriate to delegate to the nursing assistant?
- A. Assist the child to remove outer clothing
- B. Advise the parent to use acetaminophen instead of aspirin
- C. Explain the need for cool fluids
- D. Prepare and administer a tepid bath
Correct Answer: A
Rationale: Removing outer clothing is a simple task that does not require clinical judgment.