Nokea
A nurse is assessing a 33-year-old patient who underwent a cholecystectomy 18 hours prior. The nurse notes 500 mL of greenish-brown fluid has drained from the T-tube postoperatively. The nurse should
- A. chart these findings and reassess on the next rounding.
- B. call the physician and report the drainage.
- C. flush and irrigate the tube.
- D. chart these findings and indicate an infection is suspected.
Correct Answer: A
Rationale: Greenish-brown drainage (bile) from a T-tube post-cholecystectomy is expected (up to 500-1000 mL/day initially). The nurse should document and monitor, not assume infection or intervene unnecessarily.
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The nurse is providing discharge teaching to a client newly diagnosed with heart failure. Which statement by the client indicates an understanding of the side effects of furosemide (Lasix)?
- A. I should eat bananas, dried dates, or peaches every day.
- B. I should check my heart rate before taking this medicine.
- C. I will avoid foods containing tyramine while on this medicine.
- D. I will not take the medicine when I have to go on a long car trip.
Correct Answer: A
Rationale: Furosemide can cause potassium loss; eating potassium-rich foods like bananas, dates, or peaches shows understanding of managing this side effect.
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
- A. Edema of the extremity and pain at the incision site
- B. A temperature of 99.6°F and redness of the incision
- C. Serous drainage noted at the surgical area
- D. A loss of posterior tibial and dorsalis pedis pulses
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.
An RN is in charge of a team on a medical/surgical unit that includes an LPN. The RN understands that which of the following is an activity that falls outside the scope of practice of an LPN?
- A. administer oral medications to a client
- B. insert a nasogastric tube
- C. care for a patient with a tracheostomy
- D. develop a nursing care plan
Correct Answer: D
Rationale: Developing a nursing care plan requires assessment and critical thinking, which are RN responsibilities. LPNs can perform the other tasks within their scope.
A client with cocaine addiction would most likely be placed on which medication?
- A. Amantadine (Symmetrel)
- B. Methadone
- C. THC
- D. Disulfiram (Antabuse)
Correct Answer: A
Rationale: Amantadine is sometimes used to reduce cravings in cocaine addiction by modulating dopamine pathways, unlike the other options, which are used for different substance dependencies.
A client who is three days postpartum and is bottle-feeding her infant calls the nurse at the gynecology clinic with complaints of breast engorgement. What instruction should the nurse provide?
- A. reduce fluid intake to 1,500 ml/day
- B. take a warm shower twice a day
- C. apply a tight binder around her breasts
- D. come in to see the physician immediately as this is abnormal
Correct Answer: C
Rationale: A tight binder helps relieve breast engorgement by suppressing lactation in bottle-feeding mothers, a normal postpartum occurrence.