Nokea
A postoperative client returns to the nursing unit following a ureter lithotomy via a flank incision. Which potential nursing problem has the highest priority when planning nursing care for this client?
- A. Ineffective airway clearance
- B. Altered nutrition less than body requirements
- C. Fluid volume excess
- D. Activity intolerance
Correct Answer: A
Rationale: The correct answer is A: Ineffective airway clearance. After a ureter lithotomy, the client may be at risk for respiratory complications due to anesthesia, pain, and immobility. Ineffective airway clearance can lead to hypoxia and respiratory distress, making it the highest priority. Altered nutrition, fluid volume excess, and activity intolerance are important but are secondary to the immediate threat of compromised airway and breathing in the postoperative period. Therefore, addressing airway clearance first is crucial to ensure optimal client outcomes.
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A 17-year-old female is seen in the school clinic for an evaluation of abdominal pain and dysmenorrhea. The client's last menstrual period was 3 weeks ago, and her vital signs are within normal limits. Which action should the nurse take first?
- A. Refer the client to a healthcare provider for a pelvic examination
- B. Notify the parents that the client needs to be picked up from school
- C. Determine the date of the client's last menstrual period
- D. Ask the client to lie down for a pelvic examination
Correct Answer: A
Rationale: The correct answer is A: Refer the client to a healthcare provider for a pelvic examination. This is the first action the nurse should take because the client is experiencing abdominal pain and dysmenorrhea, which could indicate a gynecological issue. A pelvic examination by a healthcare provider is necessary to assess for any potential reproductive system problems, such as ovarian cysts, endometriosis, or pelvic inflammatory disease. This examination will provide valuable information to diagnose and treat the underlying cause of the client's symptoms.
Choice B is incorrect because notifying the parents to pick up the client does not address the primary concern of evaluating the abdominal pain and dysmenorrhea. Choice C is also incorrect as determining the date of the client's last menstrual period, while important, does not take precedence over a thorough pelvic examination. Choice D is incorrect as asking the client to lie down for a pelvic examination should only be done by a healthcare provider in a proper clinical setting, not in a school clinic.
The nurse is caring for a client who is receiving heparin therapy. Which laboratory value should the nurse monitor to determine the effectiveness of the therapy?
- A. Prothrombin time (PT)
- B. Partial thromboplastin time (PTT)
- C. International normalized ratio (INR)
- D. Activated partial thromboplastin time (aPTT)
Correct Answer: C
Rationale: Rationale:
1. Heparin primarily affects the intrinsic pathway of coagulation.
2. International Normalized Ratio (INR) is used to monitor the effectiveness of anticoagulation therapy.
3. INR is more specific for monitoring heparin therapy compared to other options.
4. Prothrombin Time (PT) and Activated Partial Thromboplastin Time (aPTT) are not as accurate for heparin monitoring.
5. Partial Thromboplastin Time (PTT) is used to monitor heparin therapy, but INR is a more precise indicator of heparin's effect.
While assessing a client who is experiencing Cheyne-Stokes respirations, the nurse observes periods of apnea. What action should the nurse implement?
- A. Elevate the head of the client's bed
- B. Auscultate the client's breath sounds
- C. Measure the length of the apneic periods
- D. Suction the client's oropharynx
Correct Answer: C
Rationale: The correct answer is C: Measure the length of the apneic periods. This action is crucial in assessing the severity of Cheyne-Stokes respirations and guiding further interventions. By measuring the length of apneic periods, the nurse can determine the duration of respiratory pauses and their impact on oxygenation. This information helps in deciding the appropriate treatment, such as administering supplemental oxygen or notifying the healthcare provider. Elevating the head of the bed (choice A) can help with breathing but does not address the root cause. Auscultating breath sounds (choice B) is important but does not directly address the apneic periods. Suctioning the oropharynx (choice D) is not indicated unless there is an airway obstruction.
The nurse-manager of a perinatal unit is notified that one client from the medical-surgical unit needs to be transferred to make room for new admissions. Which client should the nurse recommend for transfer to the antepartal unit?
- A. A 45-year-old with chronic hepatitis B.
- B. A 35-year-old with lupus erythematosus
- C. A 19-year-old diagnosed with rubella
- D. A 25-year-old with herpes lesions of the vulva
Correct Answer: B
Rationale: The correct answer is B: A 35-year-old with lupus erythematosus. This client should be recommended for transfer to the antepartal unit because lupus erythematosus is an autoimmune disorder that can affect pregnancy outcomes. The antepartal unit is better equipped to provide specialized care for high-risk pregnancies, which would be necessary for a client with lupus.
A: A 45-year-old with chronic hepatitis B - Hepatitis B does not directly impact pregnancy outcomes and does not require transfer to the antepartal unit.
C: A 19-year-old diagnosed with rubella - Rubella is a viral infection that can be harmful during pregnancy, but the client should be managed in a different unit specialized in infectious diseases.
D: A 25-year-old with herpes lesions of the vulva - Herpes lesions of the vulva can be managed in the medical-surgical unit and do not necessarily require transfer to the antepartal unit unless there
The client diagnosed with a right fractured femur has skeletal traction applied to the right femur. Which interventions should the nurse implement?
- A. Perform passive range of motion to the right leg
- B. Remove skeletal weights every shift to assess right leg
- C. Turn frequently from prone to supine positions
- D. Maintain skeletal pin sites and assess for signs of infection
Correct Answer: D
Rationale: The correct answer is D: Maintain skeletal pin sites and assess for signs of infection. This is important to prevent complications like infection, which can be severe. The nurse should regularly assess the pin sites for redness, swelling, or discharge. This intervention ensures early detection and prompt treatment of any signs of infection, reducing the risk of serious complications.
Choice A is incorrect because performing passive range of motion to the right leg may disrupt the traction and interfere with the healing process.
Choice B is incorrect because removing skeletal weights every shift can lead to loss of traction, compromising the fracture alignment and healing process.
Choice C is incorrect because turning the client frequently from prone to supine positions may also disrupt the traction and increase the risk of complications.