Nokea
Health History
45-year-old female admitted for laparoscopic cholecystectomy. The client recently had a weight loss of ten kilograms through dieting, and cholelithiasis was subsequently discovered. The client is alert and oriented x 4. No known drug allergies. No surgical history. The client takes levothyroxine for hypothyroidism.
• Vital Signs
Oral temperature 97 F (36° C); Pulse 90 bpm; Respirations 18; BP 110/64 mm Hg; Oxygen saturation 96% on room air.
A nurse is caring for a client in a surgery center scheduled for laparoscopic cholecystectomy.Click to specify if the nursing intervention is completed during the preoperative, intraoperative, or postoperative phase. Each intervention may be completed in more than one phase. Each row must have at least one but may have more than one response option selected.
- A. Verify the client’s name and date of birth
- B. Verify the client’s nothing-by-mouth (NPO) status
- C. Administration of prophylactic antibiotic
- D. Obtaining laboratory work such as complete blood count, clotting studies, and pregnancy test
- E. Assessment of the surgical incision site for type and amount drainage
- F. Verifying that the informed consent has been completed
- G. Confirming the correct sponge and instrument count
Correct Answer:
Rationale:
You may also like to solve these questions
The following scenario applies to the next 1 items
The infection control nurse is reviewing transmission-based precautions for assigned clients.
Item 1 of 1
Client 1 Client 2 Client 3 Client 4 Client 5
• Admitted two days ago with fever, fatigue, hemoptysis, and pleuritic chest pain.
Purified protein derivative test: reactive.
Intravenous fluids and antipyretics prescribed.
Airborne precautions
The infection control nurse is reviewing transmission-based precautions for assigned clients. Client 1: Admitted two days ago with fever, fatigue, hemoptysis, and pleuritic chest pain. Purified protein derivative test: reactive. Intravenous fluids and antipyretics prescribed. Airborne precautions. Click to specify if the transmission-based precaution is appropriate or not appropriate for each client.
- A. Client 1
- B. Client 2
- C. Client 3
- D. Client 4
- E. Client 5
- F. Client 6
- G. Client 7
Correct Answer: A
Rationale: Airborne precautions are appropriate for Client 1 due to symptoms and a reactive PPD test, suggesting possible tuberculosis, which requires airborne precautions.
The infection control nurse is responding to an outbreak of norovirus in the facility. The nurse should recommend that
- A. staff wears a surgical mask when providing client care.
- B. disposable utensils and dishware are used for meals.
- C. dietary staff wears a face shield when preparing client meals.
- D. commonly touched surfaces be disinfected with a bleach solution.
Correct Answer: D
Rationale: Norovirus requires contact precautions, including bleach disinfection of surfaces. Masks, disposable utensils, and face shields are not standard.
The nurse is providing patient teaching to the mother of a child with a banana allergy. The nurse would be most correct in informing the mother that this child is at an increased risk of developing an allergy to which of the following?
- A. Penicillin
- B. Cat dander
- C. Latex
- D. Peanuts
Correct Answer: C
Rationale: Banana allergy is associated with latex-fruit syndrome, increasing latex allergy risk. Penicillin, cat dander, and peanuts are unrelated.
The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The nurse should take which action to prepare for the surge in clients? Select all that apply.
- A. Work to arrange timely discharge and admission for appropriate clients.
- B. Establish a holding area for discharged clients not able to go home.
- C. Modify the nurse/client ratio to accommodate the surge levels.
- D. Instruct staff to switch from electronic to paper documentation.
- E. Prepare to provide frequent updates to local media.
Correct Answer: A,B
Rationale: Timely discharges/admissions and a holding area optimize resources. Modifying nurse ratios, switching to paper documentation, or media updates are not primary actions.
The nurse is recommending respite care to a client and their caregiver. The nurse understands that this care is designed to
- A. Improve the quality of life of clients and families who are experiencing problems related to life-threatening illnesses.
- B. Provide a variety of health and social services to specific patient populations.
- C. Have clients live with comfort, independence, and dignity while easing the pain of terminal illness.
- D. Offers short-term relief by providing caregivers who support the ill, disabled, or frail older adults time to relax.
Correct Answer: D
Rationale: Respite care provides temporary relief for caregivers, allowing them rest. Other options describe palliative or comprehensive care services.