Nokea
During a home visit to an older client living alone post-coronary artery bypass graft, what finding prompts the nurse to consider additional referrals?
- A. Dirty carpets requiring vacuuming
- B. Expired food found in the refrigerator
- C. Outdated medications stored in the kitchen
- D. Presence of multiple cats in the home
Correct Answer: B
Rationale: The correct answer is B (Expired food found in the refrigerator) because it poses a potential health risk to the client. Expired food can lead to foodborne illnesses, especially for an older adult post-surgery. Dirty carpets (choice A) may not directly impact the client's health. Outdated medications (choice C) can be addressed by the nurse without additional referrals. The presence of multiple cats (choice D) may be a concern for allergies or cleanliness, but it is not as urgent as expired food in terms of health risks.
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A nurse is caring for a client post-myocardial infarction (MI). What is the priority assessment for this client?
- A. Monitoring urine output
- B. Checking blood glucose levels
- C. Assessing for chest pain
- D. Monitoring electrolyte levels
Correct Answer: C
Rationale: The correct answer is C: Assessing for chest pain. The priority assessment for a client post-MI is to monitor for any signs of recurrent chest pain or angina, as it could indicate ongoing cardiac ischemia or a new infarction. Prompt intervention is crucial in these situations to prevent further damage to the heart muscle. Monitoring urine output (A) and electrolyte levels (D) are important assessments but do not take precedence over assessing for chest pain. Checking blood glucose levels (B) is relevant for diabetic clients but is not the priority in this case.
A healthcare provider is assessing a client who had a myocardial infarction. Upon auscultating heart sounds, the provider hears the following sound. What action by the provider is most appropriate?
- A. Assess the client's lung sounds.
- B. Call the Rapid Response Team.
- C. Have the client sit upright.
- D. Listen to the client's lung sounds.
Correct Answer: A
Rationale: The correct answer is A: Assess the client's lung sounds. This is important because after a myocardial infarction, there is a risk of pulmonary edema, which can present as crackles or wheezes in the lungs. By assessing the lung sounds, the healthcare provider can identify any signs of respiratory distress and promptly intervene if necessary.
Choice B is incorrect because calling the Rapid Response Team is not warranted based solely on abnormal heart sounds. Choice C is incorrect as having the client sit upright is not directly related to addressing abnormal heart sounds. Choice D is also incorrect as it focuses solely on assessing lung sounds without considering the potential implications of the abnormal heart sounds.
What nursing action is most important initially for Ms. Jenkins with pneumococcal pneumonia?
- A. Administer humidified oxygen, as ordered
- B. Obtain an order for aspirin
- C. Auscultate the posterior basal segments for rales and rhonchi
- D. Explain the diagnosis to the patient
Correct Answer: A
Rationale: Oxygen therapy addresses hypoxemia, a primary concern in pneumonia.
During a preoperative review of systems, the patient reveals a history of renal disease. This finding suggests the need for which preoperative diagnostic tests?
- A. ECG and chest x-ray
- B. Serum glucose and CBC
- C. ABGs and coagulation tests
- D. BUN, serum creatinine, and electrolytes
Correct Answer: D
Rationale: Renal disease necessitates evaluating kidney function through tests like BUN, serum creatinine, and electrolytes.
Following a gastric resection, a 70-year-old male client is admitted to the Post-Anesthesia Care Unit (PACU). The client was extubated prior to leaving the OR suite. Upon arrival at the PACU, the nurse should first:
- A. check the client's airway to feel for the amount of air exchange, noting the rate, depth, and quality of respirations.
- B. obtain pulse and blood pressure readings, noting the rate and quality of the client's pulse.
- C. reassure the client that his surgery is over and that he is in the recovery room.
- D. review the doctor's orders to administer any medications ordered.
Correct Answer: A
Rationale: Adequate air exchange and tissue oxygenation depends upon competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but is secondary to airway management. Re-orienting a client to time, place, and person and knowing that their surgery is over is important, but is secondary to airway management and taking vital signs. Airway management takes precedence over the physician's orders, unless the orders specifically relate to airway management.