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A nurse is preparing a plan of care for a client who is postoperative following a cochlear implant insertion. Which of the following instructions should the nurse include in the plan of care?
- A. Lie on your back when sleeping.
- B. Wash your hair 24 hr after surgery.
- C. Resume your exercise routine.
- D. Eat foods that are soft
Correct Answer: D
Rationale: Soft foods are recommended to avoid strain on the surgical site, reduce the risk of dislodging packing or stitches, and promote comfort during initial healing. Lying on the back is not necessarily required unless specified by the surgeon. Hair washing within 24-48 hours post-surgery risks infection. Exercise is typically restricted initially to prevent strain on the surgical area.
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A nurse in the emergency department is caring for a client who has extensive partial and full-thickness burns of the head, neck, and chest. While planning the client's care, the nurse should identify which of the following risks as the priority for assessment and intervention?
- A. Airway obstruction
- B. Paralytic ileus
- C. infection
- D. Fluid imbalance
Correct Answer: A
Rationale: Burns on the head, neck, and chest pose a high risk for airway obstruction due to swelling and inhalation injury. Ensuring a patent airway is critical for oxygenation and survival, taking precedence over other concerns.
A nurse is caring for a client who has myelosuppression after receiving chemotherapy. The nurse should monitor the client for which of the following adverse effects?
- A. Anorexia and malnutrition
- B. Diarrhea and dehydration
- C. Bleeding from the gums
- D. Full body alopecia
Correct Answer: C
Rationale: Myelosuppression can cause thrombocytopenia, increasing bleeding risk, including from gums. Anorexia, diarrhea, and alopecia are chemotherapy side effects but not directly related to myelosuppression.
A nurse is assessing a client who is receiving one unit of packed RBCs to treat intraoperative blood loss. The client reports chills and back pain, and the client's blood pressure is 80/64 mm Hg. Which of the following actions should the nurse take first?
- A. Stop the infusion of blood,
- B. Inform the provider.
- C. Obtain a urine specimen.
- D. Notify the laboratory.
Correct Answer: A
Rationale: Symptoms suggest an acute hemolytic transfusion reaction, a life-threatening emergency. Stopping the transfusion immediately is critical to prevent further reaction and hemolysis.
A nurse in a burn treatment center is caring for a client who is admitted with severe burns to both lower extremities and is scheduled for an escharotomy. The client's spouse asks the nurse what the procedure entails. Which of the following nursing statements is appropriate?
- A. A piece of healthy skin will be removed from an unburned area and grafted over the burned area.
- B. Large incisions will be made in the eschar to improve circulation.
- C. The procedure involves placing the client into a shower and removing the dead tissue.
- D. Dead tour will be non-surgically removed.
Correct Answer: B
Rationale: An escharotomy involves incisions through the eschar to relieve pressure and improve blood flow, preventing complications like compartment syndrome. Other options describe different procedures.
A nurse is caring for a client who reports an area of redness, warmth, tenderness and pain in the right calf. The nurse anticipates which of the following orders when notifying the provider of this finding?
- A. Obtain a venous duplex ultrasound.
- B. Obtain impedance plethysmography.
- C. Monitor Homan's sign
- D. Apply cold therapy to the affected leg
Correct Answer: A
Rationale: Symptoms suggest deep vein thrombosis (DVT), and a venous duplex ultrasound is the standard diagnostic test to confirm a thrombus. Other options are less reliable or inappropriate.