Nokea
A male client underwent a spinal fusion yesterday. Which of the following nursing assessments should alert the nurse to the development of a possible complication?
- A. Lateral rotation of the head and neck.
- B. Clear yellowish fluid on the dressing.
- C. No need to stand in order to void.
- D. Nonproductive cough.
Correct Answer: B
Rationale: Clear yellowish fluid suggests a cerebrospinal fluid leak, a serious complication requiring immediate attention.
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A 56-year-old female with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply.
- A. Treatment of recurrent malignant effusion.
- B. Diagnosis of underlying disease.
- C. Palliation of symptoms.
- D. Relief of acute respiratory distress.
- E. Removal of the cancer cells.
Correct Answer: B,C,D
Rationale: Thoracentesis diagnoses underlying disease (B), palliates symptoms like dyspnea (C), and relieves acute respiratory distress (D). It does not treat recurrent effusions or remove cancer cells.
A client with neutropenia has an absolute neutrophil count of 900. What is the client's risk of infection?
- A. Normal risk.
- B. Moderate risk.
- C. High risk.
- D. Extremely high risk.
Correct Answer: C
Rationale: An absolute neutrophil count (ANC) of 900 indicates moderate to severe neutropenia (ANC <1,000). This places the client at high risk for infection, as neutrophils are critical for fighting pathogens. Normal risk is ANC >1,500, and extremely high risk is ANC <200.
The client with vasospastic disorder (Raynaud's phenomenon) complains of cold and numbness in her fingers. The nurse assesses the client for effects of vasoconstriction. Which of the following is an early sign of vasoconstriction?
- A. Cyanosis
- B. Gangrene
- C. Pallor
- D. Rubor
Correct Answer: C
Rationale: Pallor is an early sign of vasoconstriction in Raynaud's, as reduced blood flow causes the skin to turn white. Cyanosis occurs later with prolonged ischemia, gangrene is a late complication, and rubor (redness) occurs during the hyperemic phase after vasospasm resolves.
A nurse is caring for a client 24 hours after he has undergone an abdominal-perineal resection for a bowel tumor. The client's wife asks if she can bring him some of his favorite home-cooked Italian minestrone soup. What would be an appropriate action by the nurse?
- A. Auscultate for bowel sounds.
- B. Ask the client if he feels hunger or gas pains.
- C. Consult the dietician.
- D. Encourage the wife to bring the soup.
Correct Answer: A
Rationale: Auscultating for bowel sounds assesses whether the client's bowel function has returned post-surgery, which determines if oral intake like soup is safe.
In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?
- A. The rehabilitation plan will be guided by it.
- B. Functional status before the stroke will help predict outcomes.
- C. It will help the client recognize his physical limitations.
- D. The client can be expected to regain much of his functioning.
Correct Answer: A
Rationale: A pre-stroke functional status history guides the rehabilitation plan by setting realistic goals based on prior abilities. Predicting outcomes, recognizing limitations, or expecting full recovery are secondary or unrealistic.