Nokea
A nurse is caring for a client who had a surgical repair of an abdominal aortic aneurysm 3 days ago. The clients vital signs are: temperature 38.3° C (100.9° F), heart rate 80/min, respirations 16/min, and blood pressure 128/76 mm Hg. Which of the following actions is the nurses priority?
- A. Administer an antipyretic for the fever.
- B. Encourage the client to ambulate.
- C. Assess the surgical incision for signs of infection.
- D. Increase IV fluid administration.
Correct Answer: C
Rationale: The correct answer is C: Assess the surgical incision for signs of infection. This is the priority because the client has a fever (indicating possible infection) post-surgery, putting them at risk for complications. Assessing the surgical incision allows for early detection of infection, prompt treatment, and prevention of further complications. Administering an antipyretic (choice A) only addresses the symptom but not the underlying cause. Encouraging ambulation (choice B) and increasing IV fluids (choice D) are important but assessing for infection takes precedence due to the potential severity of an infected surgical site.
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A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of type 1 diabetes?
- A. Ketones in the urine
- B. Weight gain
- C. Hypotension
- D. Decreased hunger
Correct Answer: A
Rationale: The correct answer is A: Ketones in the urine. In type 1 diabetes, the body cannot produce insulin, leading to high blood sugar levels and breakdown of fats for energy, resulting in ketones in the urine. Weight gain (B) is unlikely as type 1 diabetes is associated with weight loss. Hypotension (C) is not a typical manifestation. Decreased hunger (D) is more commonly seen in type 2 diabetes.
A nurse is caring for a client who has deep-vein thrombosis and is receiving heparin via continuous IV infusion. The clients weight is 80 kg (176.4 lb). Using the client information provided, which of the following actions should the nurse take?
- A. Increase the infusion rate.
- B. Administer protamine sulfate immediately.
- C. Stop the heparin infusion for 1 hr.
- D. Decrease the heparin dose.
Correct Answer: C
Rationale: The correct answer is C: Stop the heparin infusion for 1 hr. This is because the client's weight is crucial in determining the appropriate heparin dosage. Heparin is usually dosed based on the client's weight to prevent complications such as bleeding or clotting. In this case, the client's weight of 80 kg indicates a specific dose range for heparin. Stopping the infusion for 1 hour allows the nurse to reassess the client's condition and potentially adjust the heparin dosage to ensure it is safe and effective.
A: Increasing the infusion rate without proper assessment can lead to overdose and increased risk of bleeding.
B: Administering protamine sulfate is the antidote for heparin overdose, not indicated in this scenario.
D: Decreasing the heparin dose without assessment may result in inadequate anticoagulation and increased risk of clot formation.
A nurse is caring for a client who has dumping syndrome following a gastric resection. The nurse should monitor the client for which of the following complications of dumping syndrome?
- A. Hyperkalemia
- B. Hypoglycemia
- C. Iron-deficiency anemia
- D. Hypertension
Correct Answer: C
Rationale: The correct answer is C: Iron-deficiency anemia. Dumping syndrome following a gastric resection can lead to rapid emptying of the stomach contents into the small intestine, causing malabsorption of nutrients, especially iron. Iron-deficiency anemia can develop due to inadequate iron absorption. Monitoring for anemia is crucial in these clients.
Hyperkalemia (A), hypoglycemia (B), and hypertension (D) are not typical complications of dumping syndrome. Hyperkalemia is high potassium levels, hypoglycemia is low blood sugar, and hypertension is high blood pressure, which are not directly associated with dumping syndrome.
A nurse is caring for a client who is receiving peritoneal dialysis. Which of the following actions should the nurse take?
- A. Report cloudy dialysate drainage to the provider.
- B. Lower the drainage bag below the level of the abdomen.
- C. Encourage fluid intake of 3L per day.
- D. Use sterile gloves only when removing the catheter.
Correct Answer: A
Rationale: The correct answer is A: Report cloudy dialysate drainage to the provider. Cloudy dialysate drainage can indicate infection, leading to peritonitis. The nurse should report this immediately for further evaluation and treatment to prevent complications. Lowering the drainage bag below the abdomen (B) can cause backflow, increasing the risk of contamination. Encouraging fluid intake of 3L per day (C) is a general recommendation but not specific to peritoneal dialysis. Using sterile gloves only when removing the catheter (D) is incorrect as sterile technique is required during all catheter manipulations in peritoneal dialysis.
A nurse is caring for a client who is 24 hr postoperative following a total hip arthroplasty. Which of the following actions should the nurse take?
- A. Maintain abduction of the affected extremity.
- B. Position the client in high Fowlers position.
- C. Encourage the client to cross their legs at the ankles.
- D. Have the client bend forward at the waist while sitting.
Correct Answer: A
Rationale: The correct answer is A: Maintain abduction of the affected extremity. This is crucial post total hip arthroplasty to prevent dislocation. Abduction helps keep the hip joint stable and reduces the risk of the prosthesis slipping out of place. Choices B, C, and D are incorrect. High Fowler's position (B) is not necessary for this specific postoperative care. Crossing legs at the ankles (C) can lead to hip dislocation. Having the client bend forward at the waist (D) can also increase the risk of dislocation.