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A male client is returned to the surgical unit following a left nephrectomy and is medicated with morphine. His dressing has a small amount of bloody drainage, and a Jackson-Pratt bulb surgical drainage device is in place. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Monitor urine output hourly
- B. Assess for back muscle aches
- C. Record drainage from the drain
- D. Obtain body weight daily
Correct Answer: C
Rationale: The most important intervention for the nurse to include in the client's plan of care following a left nephrectomy with a Jackson-Pratt bulb in place is to record drainage from the drain. Monitoring the drainage is crucial as it helps assess for potential complications such as hemorrhage, infection, or other issues related to the surgical site. Assessing urine output is important post-nephrectomy but not as critical as directly monitoring the drainage. Assessing for back muscle aches may be relevant for pain management but not as crucial as monitoring the drainage. Obtaining body weight daily is not directly related to assessing the surgical drain output and is less critical in this scenario.
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The client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action for the nurse to initiate?
- A. Encourage continued use of the 3-point crutch gait by the client
- B. Encourage the client to use a wheelchair for mobility
- C. Instruct the client in the use of a 4-point crutch gait
- D. Instruct the client in the use of a 2-point crutch gait
Correct Answer: C
Rationale: In this scenario, the client needs to avoid weight-bearing on the left leg. A 4-point crutch gait involves using both crutches and both legs, making it more appropriate for weight-bearing restrictions. Encouraging the use of a 3-point gait (choice A) would not provide adequate support for the client's condition. While using a wheelchair (choice B) could be an option, instructing the client in a 4-point crutch gait would promote mobility while adhering to weight-bearing restrictions. A 2-point crutch gait (choice D) involves using both crutches and one leg, which is not suitable for avoiding weight-bearing on the left leg.
A woman at 24-weeks gestation who has fever, body aches, and has been coughing for the last 5 days is sent to the hospital with admission prescriptions for H1N1 influenza. Which action has the highest priority?
- A. Administer Ringer's Lactate IV 125ml/8 hours
- B. Obtain specimens for cultures
- C. Assign a private room
- D. Monitor vital signs q4 hours
Correct Answer: C
Rationale: Assigning a private room has the highest priority in this scenario. It helps prevent the spread of H1N1 influenza to other patients and protects both the patient and others from potential infection. Obtaining specimens for cultures and monitoring vital signs are important but do not address the immediate need to prevent the spread of the virus. Administering Ringer's Lactate IV is not the priority in this case as it does not directly address the infectious nature of the condition.
The nurse notes that a depressed female client has been more withdrawn and non-communicative during the past two weeks. Which intervention is most important to include in the updated plan of care for this client?
- A. Encourage the client's family to visit more often
- B. Schedule a daily conference with the social worker
- C. Encourage the client to participate in group activities
- D. Engage the client in a non-threatening conversation
Correct Answer: D
Rationale: Engaging the client in a non-threatening conversation is crucial as it can help build trust and provide support, addressing the client's withdrawal. This intervention focuses on establishing a therapeutic relationship and giving the client an opportunity to express their feelings. Choices A, B, and C do not directly target the client's need for communication and may not address the underlying issues contributing to her withdrawal. Encouraging the client's family to visit more often (Choice A) may add pressure or discomfort to the client. Scheduling a daily conference with the social worker (Choice B) may not address the client's immediate need for communication. Encouraging the client to participate in group activities (Choice C) may be overwhelming for the client and not address her withdrawal directly.
The nurse is caring for a group of clients on a surgical unit. Which client should the nurse assess first?
- A. A client who is two days post knee surgery and describes pain at a "4" on a 1 to 10 scale
- B. A client who is one day post bowel resection with no bowel sounds
- C. A client who is 8 hours post appendectomy with urinary output of 480 ml
- D. A client who was admitted with severe abdominal pain and suddenly has no pain
Correct Answer: D
Rationale: The correct answer is D. A sudden absence of pain in a client with severe abdominal pain may indicate a serious condition such as internal bleeding. This sudden change in pain status requires immediate assessment to rule out any life-threatening complications. Choices A, B, and C do not indicate an acute change in the client's condition that would necessitate immediate attention compared to sudden pain relief in a client with severe abdominal pain.
What should the nurse monitor for during the IV infusion of vasopressin (Pitressin) in a client with bleeding esophageal varices?
- A. Vasodilatation of the extremities
- B. Chest pain and dysrhythmia
- C. Hypotension and tachycardia
- D. Decreasing GI cramping and nausea
Correct Answer: B
Rationale: During the IV infusion of vasopressin in a client with bleeding esophageal varices, the nurse should monitor for chest pain and dysrhythmia. Vasopressin is a vasoconstrictor that can cause cardiovascular effects, including chest pain and dysrhythmias. Options A, C, and D are incorrect as vasopressin is not expected to cause vasodilatation of the extremities, hypotension, tachycardia, or improvements in GI symptoms such as cramping and nausea.