Nokea
A nurse is caring for a client who is postoperative. For which of the following findings should the nurse suspect the client is experiencing a deep-vein thrombosis?
- A. Muscle spasms
- B. Absent pedal pulse
- C. Numbness of the affected extremity
- D. Warmth of the affected extremity
Correct Answer: D
Rationale: Warmth is a classic sign of deep-vein thrombosis due to inflammation and blood flow changes in the affected area.
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Nurses' Notes
Vital Signs
Laboratory Results
Provider Prescriptions
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.
Day 1, 1100:
Morphine administered as prescribed. IV fluids with potassium supplements initiated. Nasogastric tube inserted into left nare and set to low wall suction.
Day 4, 1000:
Client reports that abdominal pain has decreased to 3 on a scale of 0 to 10. Client states, "I feel less nauseous today and haven't vomited since yesterday." Client reports having a small bowel movement early this morning.
Physical exam:
General: Appears more comfortable, not grimacing.
HEENT: Mucous membranes moist.
Cardiovascular: S1, S2, no murmur.
Respiratory: Bilateral breath sounds clear.
Gastrointestinal:
Mild tenderness to palpation.
Bowel sounds present and more regular, less high-pitched.
Skin: No jaundice noted, skin warm and dry.
The nurse continues to assist with the care of the client.
The nurse continues to assist with the care of the client. Which of the following findings indicates that the client's condition has improved?
- A. Fluid intake
- B. Temperature
- C. Wound findings
- D. Pain level
- E. Report of nausea
- F. Bowel sounds
Correct Answer: D,E,F
Rationale: Decreased pain (from 7 to 3), reduced nausea, and more regular bowel sounds indicate improvement in the client's condition, likely due to resolution of obstruction.
A nurse is reviewing the laboratory data of a client who is scheduled for a liver biopsy. Which of the following values should the nurse report to the provider?
- A. Aspartate aminotransferase 34 units/L (0 to 34 units/L)
- B. Ammonia 55 mcg/dL (10 to 80 mcg/dL)
- C. Platelets 60,000/mm3 (150,000 to 400,000/mm3)
- D. Bilirubin 1.0 mg/dL (0.3 to 1.0 mg/dL)
Correct Answer: C
Rationale: A platelet count of 60,000/mm3 is significantly below the normal range, increasing the risk of bleeding during a liver biopsy, and should be reported to the provider.
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 reinforcing dietary teaching with a client who is postoperative and adheres to a vegetarian diet. Which of the following foods should the nurse recommend to the client as containing the highest amount of protein?
- A. Tomato soup
- B. Bananas
- C. Avocado
- D. Black beans
Correct Answer: D
Rationale: Black beans are a rich source of plant-based protein, making them the best recommendation for a vegetarian client needing protein post-surgery.