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A nurse is caring for a client who is 1 day postoperative following a transsphenoidal hypophysectomy. While assessing the client, the nurse notes a large area of clear drainage seeping from the nasal packing. Which of the following should be the nurse’s initial action?
- A. Check the drainage for glucose.
- B. Notify the client’s provider.
- C. Document the amount of drainage.
- D. Obtain a culture of the drainage.
Correct Answer: A
Rationale: The correct initial action is to check the drainage for glucose (Choice A). This is crucial because clear drainage after a transsphenoidal hypophysectomy may indicate a cerebrospinal fluid leak, which can be confirmed by the presence of glucose in the drainage. If glucose is present, it suggests leakage of cerebrospinal fluid and requires immediate intervention to prevent complications such as infection and meningitis. The other options (B, C, and D) are not the most appropriate initial actions. Notifying the provider, documenting the amount of drainage, or obtaining a culture can be important steps but should come after confirming the presence of glucose to address the immediate concern of a potential cerebrospinal fluid leak.
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A nurse is preparing to administer 0.9% sodium chloride IV infusion 1-L bag at a rate of 200 mL/hr for a client who has rhabdomyolysis. The nurse should expect the IV pump to infuse over how many hours? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 5
Rationale: To calculate the infusion time, divide the total volume (1000 mL) by the rate of infusion (200 mL/hr). This gives 5 hours for the IV pump to infuse the 1-L bag. The correct answer is 5. Other choices are incorrect because they do not result from the correct calculation. Choice A: 2 hours (incorrect, not enough time for the infusion). Choice B: 3 hours (incorrect, not enough time for the infusion). Choice C: 4 hours (incorrect, not enough time for the infusion). Choice D: 6 hours (incorrect, too long for the infusion). Choice E: 7 hours (incorrect, too long for the infusion). Choice F: 8 hours (incorrect, too long for the infusion). Choice G: 9 hours (incorrect, too long for the infusion).
A nurse is providing teaching to a client with a colostomy about appropriate food choices. Which of the following foods should the nurse include in the teaching?
- A. Dried fruits
- B. Dried peas
- C. Eggs
- D. Pasta
Correct Answer: C
Rationale: The correct answer is C: Eggs. Eggs are a good source of protein, which is important for clients with a colostomy to promote healing and overall health. They are easily digestible and less likely to cause issues like blockages or gas. Dried fruits (choice A) and dried peas (choice B) can be high in fiber and may lead to digestive problems for colostomy clients. Pasta (choice D) can also be difficult to digest and may cause discomfort. Eggs are a versatile and nutritious option that can be beneficial for clients with a colostomy.
A nurse is preparing to administer a bisacodyl suppository to a client. Which of the following actions should the nurse take? (Select all that apply)
- A. Don sterile gloves.
- B. Position the client supine with knees bent.
- C. Use a rectal applicator for insertion.
- D. Insert the suppository just beyond the internal sphincter.
- E. Lubricate the index finger.
Correct Answer: D,E
Rationale: The correct actions for administering a bisacodyl suppository are to insert it just beyond the internal sphincter (D) to ensure proper absorption and effectiveness. Lubricating the index finger (E) helps facilitate easier insertion and reduces discomfort for the client. Donning sterile gloves (A) is not necessary for this procedure. Positioning the client supine with knees bent (B) is not required; the Sims position is typically used. Using a rectal applicator for insertion (C) is not recommended for bisacodyl suppositories.
A nurse is caring for a client who has hypertension and has a potassium level of 6.8 mEq/L. Which of the following actions should the nurse take?
- A. Obtain a 12-lead ECG.
- B. Suggest that the client use a salt substitute.
- C. Ask the client to add citrus juices and bananas to her diet.
- D. Obtain a blood sample for a serum sodium level.
Correct Answer: A
Rationale: The correct answer is A: Obtain a 12-lead ECG. A potassium level of 6.8 mEq/L is significantly elevated (normal range is 3.5-5.0 mEq/L) and can lead to serious cardiac complications, such as arrhythmias. Therefore, obtaining an ECG is crucial to assess the client's cardiac status. Choice B (salt substitute) is incorrect as it can further elevate potassium levels. Choice C (citrus juices and bananas) is incorrect as these are high-potassium foods that should be avoided. Choice D (serum sodium level) is irrelevant to the client's elevated potassium level.
A nurse is preparing a client who is postoperative following a below-the-knee amputation for a leg prosthesis fitting. Which of the following actions should the nurse take?
- A. Wrap the stump with an elastic bandage in a figure-eight configuration.
- B. Remove the elastic bandage and re-wrap the stump once per day.
- C. Perform passive range of motion exercises once daily.
- D. Secure the elastic bandage to the lowest joint.
Correct Answer: A
Rationale: The correct answer is A: Wrap the stump with an elastic bandage in a figure-eight configuration. This action helps reduce swelling, provide support, and shape the stump for prosthesis fitting. Wrapping in a figure-eight pattern ensures even compression and prevents constriction. Choice B is incorrect as frequent re-wrapping can disrupt wound healing. Choice C is unnecessary and may cause discomfort. Choice D is incorrect as securing the bandage at the lowest joint can lead to constriction and hinder circulation.