Nokea
A nurse is caring for a client who has just returned from surgery to treat a fractured mandible. Which of the following items should always be available at this client's bedside? Select all that apply.
- A. Nasogastric tube.
- B. Wire cutters.
- C. Oxygen cannula.
- D. Suction equipment.
- E. Code cart.
Correct Answer: B,D
Rationale: For a client with a wired jaw due to a fractured mandible, wire cutters are essential in case of an emergency, such as vomiting, to quickly release the wires and prevent aspiration. Suction equipment is also critical to maintain a patent airway by removing secretions or vomit. A nasogastric tube, oxygen cannula, and code cart are not routinely required at the bedside unless specifically indicated.
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A client is receiving Pentoxifylline (Trental) for intermittent claudication. The nurse should determine the effectiveness of the drug by asking the client:
- A. If he has improved circulation in the legs
- B. If he can wiggle his toes
- C. If he is urinating more frequently
- D. If he is less dizzy
Correct Answer: A
Rationale: Pentoxifylline improves blood flow by reducing blood viscosity and increasing erythrocyte flexibility, alleviating intermittent claudication. Asking about improved leg circulation (e.g., reduced pain or increased walking distance) assesses its effectiveness. Toe movement, urination, and dizziness are unrelated to its therapeutic action.
After pituitary surgery, the nurse should assess the client for which of the following?
- A. Urine specific gravity less than 1.010.
- B. Urine output between 1 and 2 L/day.
- C. Blood glucose level higher than 300 mg/dL.
- D. Urine negative for glucose and ketones.
Correct Answer: A
Rationale: Low urine specific gravity (<1.010) may indicate diabetes insipidus, a common complication post-pituitary surgery due to reduced vasopressin.
The nurse is administering a medication to a client with myeloid leukemia and does not know the use, dose, or side effects. To obtain the most up-to-date information about this drug, the nurse should:
- A. Check the Physician's Drug Reference (PDR) at the nurses' station.
- B. Obtain a pharmacology textbook from the hospital library.
- C. Consult the drug guide provided by the hospital on the nurses' PDA.
- D. Review information at the drug manufacturer's website.
Correct Answer: C
Rationale: The hospital's drug guide on the nurse's PDA provides the most up-to-date and accessible information on medication use, dose, and side effects, tailored to hospital protocols. PDR and textbooks may be outdated, and manufacturer websites are less reliable for clinical use.
Which information should the nurse include when performing discharge teaching with a client who had an anterolateral approach for a total hip replacement? Select all that apply.
- A. Avoid turning the toes or knee outward.
- B. Use an abduction pillow between the legs when in bed.
- C. Use an elevated toilet seat and shower chair.
- D. Do not extend the operative leg backwards.
- E. Restrict motion for 2 weeks after surgery.
Correct Answer: A,B,C,D
Rationale: These measures prevent dislocation and promote recovery. Motion is encouraged, not restricted, to aid rehabilitation.
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply.
- A. Elevate the head of the bed to 50 degrees.
- B. Obtain daily cultures.
- C. Cover with protective dressing.
- D. Reposition the client every 2 hours.
- E. Request an alternating-pressure mattress.
Correct Answer: C,D,E
Rationale: Protective dressings, frequent repositioning, and pressure-relieving mattresses promote healing and prevent worsening of pressure ulcers. High head elevation increases shear, and daily cultures are unnecessary unless infection is suspected.