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A nurse is assessing a client who is 30 minutes postoperative following an arterial thrombectomy. What should the nurse report?
- A. Chest pain.
- B. Muscle spasms.
- C. Cool, moist skin.
- D. Incisional pain.
Correct Answer: A
Rationale: In this scenario, postoperative chest pain is a critical finding that must be reported promptly. Chest pain after an arterial thrombectomy could indicate serious complications such as myocardial infarction or pulmonary embolism. Muscle spasms and cool, moist skin are not the priority assessments in this situation. Incisional pain is common after surgery and is not typically a cause for immediate concern unless it is severe and accompanied by other symptoms.
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A nurse is preparing to administer blood to a client. Which of the following actions should the nurse take first?
- A. Check the client's identification bracelet.
- B. Obtain the client's vital signs.
- C. Initiate the transfusion slowly over the first 15 minutes.
- D. Verify the client's blood type and Rh factor.
Correct Answer: D
Rationale: The correct answer is to verify the client's blood type and Rh factor first before administering blood. This is crucial to ensure compatibility and prevent transfusion reactions. Checking the client's identification bracelet (Choice A) is important but should come after verifying blood type. Obtaining vital signs (Choice B) and initiating the transfusion slowly (Choice C) are important steps but verifying blood type is the priority to ensure safe blood administration.
A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?
- A. Change the TPN tubing every 72 hours.
- B. Monitor the client's blood glucose every 4 hours.
- C. Monitor the client's urine output every 8 hours.
- D. Use sterile technique when changing the central line dressing.
Correct Answer: D
Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.
A nurse is caring for a client who has severe hypertension and is receiving nitroprusside. What action should the nurse take?
- A. Administer oxygen and assess the client's response.
- B. Monitor blood pressure every 2 hours.
- C. Limit light exposure to the IV infusion.
- D. Attach an inline filter to the IV tubing.
Correct Answer: C
Rationale: The correct action for the nurse to take when caring for a client receiving nitroprusside for severe hypertension is to limit light exposure to the IV infusion. Nitroprusside is light-sensitive, and exposure to light can lead to degradation of the medication, reducing its effectiveness. Administering oxygen (Choice A) may be necessary for some clients but is not directly related to the administration of nitroprusside. Monitoring blood pressure every 2 hours (Choice B) is a general nursing intervention for clients with hypertension but does not specifically address the administration of nitroprusside. Attaching an inline filter to the IV tubing (Choice D) is not necessary to address the specific concern of light exposure related to nitroprusside administration.
A nurse is caring for a client who is receiving warfarin therapy. Which of the following laboratory results indicates the need for an increase in the dose of warfarin?
- A. PT 28 seconds
- B. INR 1.2
- C. aPTT 40 seconds
- D. Fibrinogen 350 mg/dL
Correct Answer: B
Rationale: An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating inadequate anticoagulation. Therefore, the client would require an increase in the dose of warfarin to achieve the desired therapeutic effect. Choices A, C, and D are not indicative of the need for a dose increase in warfarin therapy. PT of 28 seconds is within the therapeutic range, aPTT of 40 seconds is also within the normal range, and fibrinogen level of 350 mg/dL does not provide information about the anticoagulant effect of warfarin.
A nurse is assessing a client who has just received an opioid medication. Which of the following findings should the nurse monitor first?
- A. Constipation.
- B. Drowsiness.
- C. Orthostatic hypotension.
- D. Respiratory depression.
Correct Answer: D
Rationale: When a client receives an opioid medication, the nurse should first monitor for respiratory depression as it is a life-threatening adverse effect associated with opioids. This can lead to inadequate ventilation and hypoxia, requiring immediate intervention. Constipation, drowsiness, and orthostatic hypotension are also common side effects of opioids but are not as immediately life-threatening as respiratory depression.