Nokea
A nurse is continuing to care for a client who is postoperative following surgical removal of an abdominal abscess. Which of the following actions should the nurse take?
- A. Obtain vital signs every 30 minutes.
- B. Elevate the client in a semi-Fowler's position.
- C. Apply oxygen.
- D. Monitor the client's level of consciousness.
Correct Answer: B
Rationale: The correct answer is B: Elevate the client in a semi-Fowler's position. Elevating the client in a semi-Fowler's position helps promote optimal lung expansion and ventilation, reducing the risk of postoperative complications such as atelectasis and pneumonia. This position also aids in preventing aspiration and promotes comfort.
Choice A: Obtaining vital signs every 30 minutes is important postoperatively, but it is not the most immediate action needed in this case.
Choice C: Applying oxygen may be necessary depending on the client's oxygen saturation levels, but it is not the most essential action to take at this point.
Choice D: Monitoring the client's level of consciousness is important, but it is not as critical as positioning the client correctly to prevent respiratory complications.
You may also like to solve these questions
A nurse is assessing a client who has anorexia. Which of the following findings should the nurse identify as a manifestation of malnutrition?
- A. Dry skin
- B. Alopecia
- C. Increased salivation
- D. Dolichocephaly
Correct Answer: A
Rationale: The correct answer is A: Dry skin. Malnutrition can lead to a deficiency in essential nutrients like vitamins and minerals, causing skin to become dry and flaky. This occurs due to a lack of proper hydration and nourishment. Alopecia (B) is more commonly associated with conditions like stress or hormonal imbalances. Increased salivation (C) is not typically linked to malnutrition but can be seen in conditions like GERD. Dolichocephaly (D) refers to an elongated shape of the head and is not directly related to malnutrition. In summary, dry skin is a manifestation of malnutrition due to the lack of essential nutrients, while the other choices are more likely associated with different conditions or factors.
A nurse is caring for a client who has a new onset of hyperglycemic hyperosmolar state (HHS). Which of the following interventions by the nurse is the highest priority?
- A. Administer Insulin.
- B. Teach the client about manifestations of HHS.
- C. Measure the client's urinary output.
- D. Initiate IV fluid replacement.
Correct Answer: D
Rationale: The correct answer is D: Initiate IV fluid replacement. In hyperglycemic hyperosmolar state (HHS), the client is severely dehydrated due to high blood glucose levels. IV fluid replacement is the highest priority to rehydrate the client and improve circulation. Administering insulin (A) is important but not the highest priority as fluid replacement takes precedence. Teaching the client about manifestations of HHS (B) is important for long-term management but not the immediate priority. Measuring urinary output (C) is important to assess renal function but not as critical as rehydrating the client.
A nurse is caring for a client who has cervical cancer and is receiving internal radiation therapy. Which of the following actions should the nurse take?
- A. Check if the radioactive device is in the correct position.
- B. Limit time for visitors to 2 hours per day.
- C. Ask visitors to remain 3 feet from the client.
- D. Keep lead-lined aprons in the client's room.
Correct Answer: A
Rationale: The correct action for the nurse to take is to check if the radioactive device is in the correct position. This is crucial to ensure that the radiation therapy is being delivered accurately and effectively. By verifying the position of the radioactive device, the nurse can prevent potential harm to the client and ensure the success of the treatment.
Choice B is incorrect because limiting visitors' time does not directly relate to the safety and effectiveness of the radiation therapy. Choice C is incorrect as asking visitors to remain 3 feet away does not address the primary concern of verifying the device's position. Choice D is also incorrect as lead-lined aprons are typically used by healthcare providers during procedures, not by the client.
A nurse is caring for an older adult client who reports vaginal dryness and itching. Which of the following responses should the nurse make?
- A. These discomforts should decrease with time.'
- B. You should avoid intercourse to prevent injury to your vagina.'
- C. Women your age experience thickening of the vaginal tissue.'
- D. Your symptoms are likely due to decreasing estrogen levels.'
Correct Answer: D
Rationale: The correct answer is D: "Your symptoms are likely due to decreasing estrogen levels." This response is correct because vaginal dryness and itching are common symptoms of vaginal atrophy, which is often caused by decreased estrogen levels in older adult women. The nurse's acknowledgment and explanation of this physiological change can help the client understand the root cause of her symptoms and guide further discussion on appropriate treatment options, such as hormone therapy or vaginal moisturizers.
Choice A is incorrect because it dismisses the client's discomfort without addressing the underlying cause. Choice B is incorrect as it provides potentially harmful advice without addressing the issue. Choice C is incorrect as it inaccurately describes the condition of vaginal tissue in older women.
A nurse is providing teaching for a client who has diabetes mellitus about the self-administration of insulin. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will draw up the regular insulin into the syringe first.
- B. I will shake the NPH vial vigorously before drawing up the insulin.
- C. I will store prefilled syringes in the refrigerator with the needle pointed downward.
- D. I will insert the needle at a 15-degree angle.
Correct Answer: A
Rationale: Correct Answer: A - "I will draw up the regular insulin into the syringe first."
Rationale: Drawing up regular insulin before NPH prevents contamination. Regular insulin has a clear appearance, making it easier to detect any contamination. Drawing up NPH first can cause regular insulin to be contaminated if the same syringe is used. This statement demonstrates an understanding of the importance of preventing contamination and following proper insulin administration technique.
Summary of Incorrect Choices:
B: Shaking the NPH vial vigorously can cause air bubbles, affecting the accuracy of the dose.
C: Storing prefilled syringes in the refrigerator with the needle downward can cause leakage or contamination.
D: Inserting the needle at a 15-degree angle may not be appropriate for insulin injection, which typically requires a 90-degree angle for subcutaneous administration.