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A nurse is monitoring a client following a lumbar laminectomy. The client has a drain and indwelling urinary catheter. The nurse should identify which of the following findings as an indication of a complication of the surgery?
- A. Red-tinged drainage on the dressing
- B. Cloudy urine in the catheter
- C. Clear drainage on the dressings
- D. Mild back pain at the surgical site
Correct Answer: C
Rationale: The correct answer is C: Clear drainage on the dressings. Clear drainage may indicate a cerebrospinal fluid leak, which is a serious complication following a lumbar laminectomy. Cerebrospinal fluid is a clear fluid that surrounds the brain and spinal cord, and its leakage can lead to infection and other complications. Red-tinged drainage (choice A) may be expected initially due to surgical trauma. Cloudy urine in the catheter (choice B) is more likely related to urinary tract infection. Mild back pain at the surgical site (choice D) is common after this surgery and does not necessarily indicate a complication.
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A nurse is caring for a client who is receiving vancomycin intermittent IV bolus therapy for methicillin-resistant Staphylococcus aureus (MRSA). Which of the following findings is an indication to the nurse that the client is experiencing an adverse effect of the medication?
- A. The client reports ringing in the ears.
- B. The client is becoming flushed.
- C. The client reports increased thirst.
- D. The client has a decreased urine output.
Correct Answer: B
Rationale: The correct answer is B: The client is becoming flushed. Flushing is a common adverse effect of vancomycin, indicating a possible allergic reaction or infusion reaction. Flushing can be a sign of red man syndrome, a severe reaction to vancomycin. The nurse should monitor closely and report this finding to the healthcare provider.
Incorrect Answer Rationale:
A: The client reports ringing in the ears - this is a potential adverse effect of vancomycin, but not as critical as flushing.
C: The client reports increased thirst - this is not typically associated with vancomycin adverse effects.
D: The client has a decreased urine output - this may indicate nephrotoxicity, a known side effect of vancomycin, but flushing is more indicative of an immediate adverse reaction.
A nurse is preparing to administer potassium chloride 10 mEq IV over 1 hr to a client. Available is potassium chloride 10 mEq in 100 mL of 0.9% sodium chloride. The nurse should set the infusion pump to deliver how many mL/hr? (Round the answer to the nearest whole number.)
- A. 50 mL/hr
- B. 75 mL/hr
- C. 100 mL/hr
- D. 125 mL/hr
Correct Answer: C
Rationale: To calculate the infusion rate, we need to use the formula: (Desired dose ÷ Volume) x 60 minutes. In this case, the desired dose is 10 mEq over 1 hour, and the volume is 100 mL.
So, (10 ÷ 100) x 60 = 6 mL/hr. Therefore, the nurse should set the infusion pump to deliver 100 mL/hr. This ensures the correct administration of potassium chloride over the specified time frame.
Choice A (50 mL/hr) and B (75 mL/hr) are incorrect as they would result in the underdosing of potassium chloride. Choice D (125 mL/hr) is incorrect as it would result in the overdosing of potassium chloride. The correct answer, C (100 mL/hr), ensures the proper administration of the medication within the specified parameters.
A nurse is planning preventative strategies for a client who is at risk for pressure injuries. Which of the following actions should the nurse include in the plan?
- A. Apply moisturizer to damp skin after bathing.
- B. Massage bony prominences to improve circulation.
- C. Use cornstarch powder to keep skin dry.
- D. Position the client at a 90-degree angle in bed.
Correct Answer: A
Rationale: The correct answer is A: Apply moisturizer to damp skin after bathing. Moisturizing helps maintain skin integrity and hydration, reducing the risk of pressure injuries. When skin is damp, it is more receptive to hydration, which can prevent dryness and breakdown. Applying moisturizer also helps to maintain the skin's natural barrier function. Massaging bony prominences (choice B) can actually increase the risk of pressure injuries by causing friction and shearing forces. Using cornstarch powder (choice C) can lead to moisture buildup and increase the risk of skin breakdown. Positioning the client at a 90-degree angle in bed (choice D) is not a recommended preventive strategy for pressure injuries.
A nurse is assessing a client who takes salmeterol to treat moderate asthma. Which of the following findings should indicate to the nurse that the medication has been effective?
- A. The client has decreased mucus production.
- B. The clients daily peak expiratory flow (PEF) measures 85% above personal best.
- C. The client has a respiratory rate of 24/min.
- D. The client reports no nighttime coughing.
Correct Answer: B
Rationale: The correct answer is B because an increase in the client's daily peak expiratory flow (PEF) by 85% above their personal best indicates improved lung function, which is a positive response to salmeterol. This demonstrates that the medication is effectively managing the asthma symptoms.
Choice A is incorrect because decreased mucus production is not a direct indicator of salmeterol's effectiveness in treating asthma. Choice C is incorrect as the respiratory rate alone does not provide specific information about the medication's effectiveness. Choice D is incorrect since the absence of nighttime coughing may be due to various factors and not solely because of salmeterol's effectiveness.
A nurse is admitting an older adult client who is transferring from another facility. The nurse notes pressure ulcers on the clients coccyx and abrasions around both wrists. Which of the following actions should the nurse take to address suspicions of elder abuse?
- A. Notify risk management.
- B. Inform the transferring agency of the clients condition.
- C. Contact the family regarding the clients condition.
- D. Privately interview the client about the injuries.
Correct Answer: D
Rationale: Correct Answer: D - Privately interview the client about the injuries.
Rationale:
1. As a healthcare provider, the nurse must prioritize the well-being and safety of the client.
2. Privately interviewing the client allows for a confidential conversation to gather information directly from the client.
3. This approach respects the client's autonomy and confidentiality.
4. It enables the nurse to assess the situation, gather more details, and determine if further actions are needed to address the suspected elder abuse.
5. Notifying risk management (A) is important but should come after gathering information from the client.
6. Informing the transferring agency (B) may not address the immediate concern of potential abuse.
7. Contacting the family (C) may not be appropriate if they are involved in the abuse.
8. Failing to interview the client may result in a missed opportunity to address the issue effectively.
Summary:
Option D is correct as it prioritizes the client's well-being, respects autonomy, and