Nokea
A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?
- A. The client arouses easily but quickly falls back asleep.
- B. There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.
- C. There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.
- D. The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.
Correct Answer: A
Rationale: Difficulty staying awake 6 hours post-op suggests potential respiratory depression or neurological issues, a priority to report.
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A nurse is assisting a provider with a thoracentesis for a client who is experiencing respiratory distress. Which of the following actions should the nurse take?
- A. Insert an indwelling urinary catheter and record the client's output.
- B. Set up the equipment using clean technique.
- C. Prepare the client for a chest x-ray following the procedure.
- D. Instruct the client to remain flat in bed for 4 to 6 hr after the procedure.
Correct Answer: C
Rationale: A chest x-ray post-thoracentesis confirms lung re-expansion and checks for complications like pneumothorax.
Nurses' Notes
Vital Signs
Day 1, 1000:
The client reports mid abdominal pain. Client reports pain as 7 on a scale of 0 to 10. The client states, "I haven't had a bowel movement in 4 days. The client states, “I also have vomited, once or twice."
Physical Exam:
General: uncomfortable, grimacing
HEENT: dry mucous membranes
Cardiovascular: S1, S2, no murmur
Respiratory: bilateral breath sounds clear
Gastrointestinal: tenderness to palpation, high-pitched bowel sounds
Skin: no jaundice noted
Social history: drinks 1 to 2 glasses of wine daily. Client reports no tobacco use.
The nurse is assisting with the care of a client. The nurse is collecting data on the client. Which of the following findings require follow-up?
- A. Blood pressure
- B. BUN level
- C. Potassium level Abdominal findings
- D. WBC count
- E. Breath sounds
Correct Answer: A,B,C,D
Rationale: Blood pressure, BUN, potassium, and abdominal findings (pain, constipation, vomiting, high-pitched bowel sounds) require follow-up due to potential dehydration or obstruction; breath sounds are normal and do not need follow-up.
A nurse is caring for a client who is 2 days postoperative following abdominal surgery. The nurse auscultates hypoactive bowel sounds, and the client reports cramping abdominal pain. Which of the following actions should the nurse take first?
- A. Administer a glycerin suppository.
- B. Ambulate the client in the hallway.
- C. Request the client to be NPO.
- D. Offer an analgesic medication.
Correct Answer: B
Rationale: Ambulating the client first promotes bowel motility, addressing hypoactive bowel sounds and cramping, a common postoperative issue.
A nurse is assisting with the care of a client who had a bronchoscopy 12 hr ago. Which of the following findings should the nurse report to the provider?
- A. The client has inspiratory stridor
- B. The client reports a sore throat.
- C. The client's sputum has streaks of blood.
- D. The client's temperature is 38.6°C / 101.4°F
Correct Answer: A
Rationale: Inspiratory stridor indicates possible airway obstruction or swelling post-bronchoscopy, a serious complication requiring immediate reporting.
A nurse is assisting with the care of an 18-year-old client who is at their provider's office for an annual physical. The client inquires about cancer examinations that they should have. Which of the following examinations should the nurse recommend?
- A. Testicular
- B. Skin
- C. Prostate
- D. Colorectal
Correct Answer: A
Rationale: Testicular self-examination is recommended for young males (e.g., 18-year-olds) to detect early signs of testicular cancer.