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A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 8:30 a.m. to compare them with the current vital signs at 10:30 p.m. (see chart). What should the nurse do fi rst?
- A. Call the physician for pain medication.
- B. Cover the client with warmed blankets.
- C. Administer oxygen at 4 L/minute.
- D. Increase the I.V. fl uid rate.
Correct Answer: B
Rationale: The client’s body temperature dropped 2.5° F from the preoperative to postoperative phase. The client lost heat during the preoperative period. The client has not had time to regain the heat she has lost and should not be discharged postoperatively until her postoperative vital signs, which include body temperature, are closer to her preoperative vital signs. The client’s pulse rate, respiratory rate, and blood pressure have compensated according to the client’s hypothermic state and will refl ect changes as the client warms up. There are no indications that the client needs more pain medication, oxygen, or I.V. fl uids.
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A client with osteoporosis needs education about diet and ways to increase bone density. Which of the following should be included in the teaching plan? Select all that apply.
- A. Maintain a diet with adequate amounts of vitamin D, as found in fortified milk and cereals.
- B. Choose good calcium sources, such as figs, broccoli, and almonds.
- C. Use alcohol in moderation because a moderate intake has no known negative effects.
- D. None of the above
Correct Answer: A,B
Rationale: Vitamin D and calcium are essential for bone health. Excessive alcohol can reduce bone density, so moderation alone is insufficient.
The nurse is assessing a client with drooping of their left eyelid. The nurse documents this finding as
- A. mydriasis.
- B. ptosis.
- C. presbyopia.
- D. hyphema.
Correct Answer: B
Rationale: Ptosis is the medical term for drooping of the eyelid. Mydriasis refers to pupil dilation, presbyopia is age-related vision loss, and hyphema is blood in the anterior chamber of the eye.
A client refuses to look at or care for her colostomy. Which of the following statements by the nurse would be most appropriate?
- A. It has been 4 days since your surgery and you will be discussed. You have to learn to care for your colostomy before you leave the hospital.
- B. I think we will need to teach your husband to care for your colostomy if you are not going to be able to do it.
- C. I understand how you are feeling. It is important for you to feel attractive and you think having a colostomy changes your attractiveness.
- D. I can see that you are upset. Would you like to share your concerns with me?
Correct Answer: D
Rationale: It is important for the nurse to recognize that individuals go through a grieving process when adjusting to a colostomy. The nurse should be accepting and provide the client with opportunities to share her concerns and feelings when she is ready. Lecturing the client about the need to learn how to care for the colostomy is not productive, nor is attempting to shame her into caring for the colostomy by implying her husband will have to provide the care if she does not. It is not possible for the nurse to understand what the client is feeling. CN: Psychosocial adaptation; CL: Synthesize
Assessment of a client taking a nonsteroidal anti-inflammatory drug (NSAID) for pain management should include specific questions regarding which of the following systems?
- A. Gastrointestinal.
- B. Renal.
- C. Pulmonary.
- D. Cardiac.
Correct Answer: A
Rationale: NSAIDs commonly cause gastrointestinal side effects, such as bleeding or ulcers, so specific assessment of the GI system is critical.
A 92-year-old male client who is independent and lives alone has an inguinal hernia repair. Which teaching method is the best approach to use for his postoperative and discharge instructions?
- A. Written instructions with diagrams.
- B. Verbal instructions with repetition.
- C. Demonstration and return demonstration.
- D. Video instructions with follow-up.
Correct Answer: C
Rationale: Demonstration and return demonstration is the most effective for an elderly client, as it ensures understanding and ability to perform postoperative care tasks, accommodating potential sensory or cognitive limitations.