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 nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescription should the nurse clarify with the primary healthcare physician (PHCP)?
- A. Lispro insulin 5 units SubQ TID
- B. Glargine insulin 15 units SubQ QHS
- C. Vitamin B12 100 mcg IM Daily
- D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days
Correct Answer: A
Rationale: Lispro insulin is a rapid-acting insulin typically administered around mealtimes to manage postprandial glucose levels. Since the client is NPO, they are not eating, so administering lispro insulin could lead to hypoglycemia due to the absence of carbohydrate intake. The nurse should clarify this prescription with the PHCP to ensure safe management of the client’s blood glucose levels during the NPO period. Glargine insulin, a long-acting insulin, is appropriate for basal glucose control and does not require clarification. Vitamin B12 and clonidine are unrelated to food intake and safe for NPO status.
The nurse is caring for a client who has pulmonary tuberculosis (TB). Which infection control measure should the nurse implement?
- A. Restrict visitors who are pregnant
- B. Remove any portable fans in the room
- C. Wear a dosimeter badge during client care
- D. Place the client further away from the nursing station
Correct Answer: B
Rationale: Portable fans can spread TB bacilli, so they should be removed. Pregnant visitors are not specifically restricted, dosimeters are for radiation, and room placement is less critical.
The following scenario applies to the next 6 items
The home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 2 of 6
Nurses' Note
Current Medications
1349: Initial home visit performed. The client was hospitalized last week for four days following a ground-level fall, delirium, and cystitis. The client is alert and fully oriented. Clear lung sounds bilaterally. Peripheral pulses 2+. Her muscle movements were uncoordinated as she missed grabbing the television remote and a can of cola. Speech was intelligible with some pauses. When ambulating to the bathroom, she used scattered furniture as assistive devices. Skin is warm, dry, and normal for ethnicity. She reports significant fatigue throughout the day. She states that during the day, the heat bothers her, so she is reluctant to go to the mailbox. She is also tired while cooking and cleaning in the evening hours. Since discharge, the client reports that she sleeps 7-8 hours, but does not feel rested in the morning. She reports that her urine is clear and without odor, but she has an urgency when going to the bathroom. She reports numbness and tingling in the lower extremities that last all day. She does report her legs 'stiffening up' intermittently throughout the day. She reports that she is taking the prescribed antibiotic when she remembers. Denies any loss of appetite and has increased her fluids with cola and sweet tea since discharge.
The nurse reviews the assessment data and analyzes the individual's risk for falling. Click to specify whether each assessment finding is a risk factor for falling or not.
- A. Ambulation pattern
- B. Speech pattern
- C. Age
- D. Gender
- E. Fall history
- F. Current medications
Correct Answer: A,C,E,F
Rationale: Ambulation pattern, age (older adults), fall history, and medications (e.g., diazepam) are fall risk factors. Speech pattern and gender are not direct risk factors.
The nurse is discussing infection control with a group of nursing students. It would be correct to state that airborne precautions are used for which condition? Select all that apply.
- A. Pulmonary tuberculosis
- B. Pertussis
- C. Rubeola
- D. Hepatitis A
- E. Rubella
Correct Answer: A,C
Rationale: Pulmonary TB and rubeola (measles) require airborne precautions due to airborne transmission. Pertussis and rubella require droplet precautions, and Hepatitis A is contact-based.
The nurse is preparing to prime a new line of IV tubing. The nurse understands that priming intravenous tubing is crucial because it prevents which treatment complication?
- A. Medication toxicity
- B. Infiltration
- C. Air embolism
- D. Extravasation
Correct Answer: C
Rationale: Priming IV tubing removes air, preventing air embolism, a potentially fatal complication. Other complications are unrelated to priming.