Nokea
A male client with angina pectoris is being discharged from the hospital. What instructions should the nurse plan to include in the discharge teaching?
- A. Engage in physical exercise before eating to help decrease cholesterol levels.
- B. Avoid walking briskly in cold weather to prevent a decrease in cardiac output.
- C. Keep nitroglycerin in a light-colored plastic bottle and readily available.
- D. Avoid all isometric exercises, but walk regularly.
Correct Answer: C
Rationale: The correct answer is to keep nitroglycerin in a light-colored container and readily available. Nitroglycerin should be protected from light to maintain its effectiveness. Option A is incorrect because physical exercise immediately before eating can trigger angina. Option B is incorrect as cold weather can exacerbate angina symptoms. Option D is incorrect as isometric exercises can increase the workload on the heart, which is not recommended for individuals with angina.
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A 5-week-old infant who developed projectile vomiting over the last two weeks is diagnosed with hypertrophic pyloric stenosis. Which intervention should the nurse plan to implement?
- A. Instruct the mother to give the child sugar water only
- B. Maintain intravenous fluid therapy per prescription
- C. Provide Pedialyte feedings via the nasogastric tube
- D. Offer the infant Pedialyte feedings every 2 hours
Correct Answer: B
Rationale: Maintaining intravenous fluid therapy is crucial for managing dehydration and electrolyte imbalances caused by the vomiting in hypertrophic pyloric stenosis. Instructing the mother to give sugar water only (Choice A) is not appropriate as it does not address the dehydration and electrolyte imbalances adequately. Providing Pedialyte feedings via the nasogastric tube (Choice C) may not be sufficient to manage the severe fluid and electrolyte losses caused by the condition. Offering Pedialyte feedings every 2 hours (Choice D) may not be as effective as maintaining intravenous fluid therapy, especially in cases where rapid rehydration is necessary.
After receiving report, which client should the nurse assess last?
- A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
- B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
- C. An older client with a distended abdomen and no drainage from the nasogastric tube
- D. An adult client with rectal tube draining clear pale red liquid drainage
Correct Answer: D
Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.
The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?
- A. An older client receiving packed RBCs on the third day postoperatively for colon resection
- B. An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery
- C. An adult one day postoperatively from laparoscopic cholecystectomy requesting pain medication
- D. An adult in Buck's traction, scheduled for hip arthroplasty within the next 12 hours
Correct Answer: B
Rationale: The correct answer is B because the client with continuous bladder irrigation post-bladder surgery is at risk for complications like infection or bleeding. This client requires immediate attention to assess for any signs of complications such as urinary retention, hemorrhage, or infection. Choices A, C, and D have less urgent needs compared to a client with continuous bladder irrigation, which requires priority assessment.
A client with intestinal obstructions has a nasogastric tube to low intermittent suction and is receiving an IV of lactated Ringer's at 100 ml/H. Which finding is most important for the nurse to report to the healthcare provider?
- A. Gastric output of 900 mL in the last 24 hours
- B. Serum potassium level of 3.1 mEq/L or mmol/L (SI)
- C. Increased blood urea nitrogen (BUN)
- D. 24-hour intake at the current infusion rate
Correct Answer: B
Rationale: The most crucial finding to report to the healthcare provider in this scenario is a serum potassium level of 3.1 mEq/L. Hypokalemia can lead to serious complications, including cardiac issues. Gastric output, increased BUN, and monitoring the 24-hour intake are essential but do not pose an immediate risk as hypokalemia does in this situation.
The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. What action should the nurse implement immediately?
- A. Change the dressing using a compression bandage
- B. Test fluid on the dressing for glucose
- C. Document the findings in the electronic medical record
- D. Mark drainage area with a pen and continue to monitor
Correct Answer: B
Rationale: The correct action for the nurse to implement immediately upon identifying clear fluid on the surgical dressing post-lumbar surgery is to test the fluid for glucose. Clear fluid could indicate cerebrospinal fluid (CSF) leakage, and testing for glucose can help confirm this. Changing the dressing using a compression bandage (Choice A) without further assessment could lead to complications. Documenting the findings (Choice C) is important but not as immediate as confirming the presence of CSF. Marking the drainage area with a pen and monitoring (Choice D) does not address the need for immediate confirmation of CSF leakage.