Nokea
A short time after cataract surgery, the client complains of nausea. The nurse should first:
- A. Instruct the client to take a few deep breaths until the nausea subsides.
- B. Explain that this is a common feeling that will pass quickly.
- C. Tell the client to call the nurse promptly if vomiting occurs.
- D. Administer an antiemetic, as ordered.
Correct Answer: D
Rationale: Nausea after cataract surgery can indicate increased intraocular pressure or other complications. Administering an antiemetic as ordered is the priority to prevent vomiting, which could increase intraocular pressure and cause complications.
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After surgery for head and neck cancer, a client has a permanent tracheostomy. The nurse should teach the client and family about the importance of:
- A. Providing tracheostomy site care.
- B. Addressing the psychosocial issues related to tracheostomy.
- C. Observing for early signs and symptoms of skin breakdown around the tracheostomy site.
- D. Using humidifiers to prevent thick, tenacious secretions.
Correct Answer: A,C,D
Rationale: Tracheostomy site care (A), monitoring for skin breakdown (C), and using humidifiers (D) are critical to prevent infection, maintain skin integrity, and keep secretions manageable.
Four days after surgery for internal fixation of a C3 to C4 fracture, a nurse is moving a client from the bed to the wheelchair. The nurse is checking the wheelchair for correct features for this client. Which of the following features of the wheelchair are appropriate for the needs of this client?
- A. Back at the level of the client's scapula.
- B. Back and head that are high.
- C. Seat that is lower than normal.
- D. Seat with firm cushions.
- E. Chair controlled by client's breath.
Correct Answer: B,D,E
Rationale: A high back and headrest provide neck stability, firm cushions prevent pressure ulcers, and a breath-controlled chair accommodates limited upper extremity function post-C3-C4 injury. A low back or lower seat height could compromise stability or transfer safety.
The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5 (0.9-1.2 seconds). The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?
- A. Packed red blood cells (PRBCs)
- B. Platelets
- C. Granulocytes
- D. Fresh frozen plasma (FFP)
Correct Answer: D
Rationale: An INR of 5 indicates significant anticoagulation from warfarin, increasing bleeding risk (evidenced by tarry stools and bloody gums). FFP provides clotting factors to reverse warfarin’s effects. PRBCs address anemia, platelets address thrombocytopenia, and granulocytes treat infections, none of which are primary here.
The goal of nursing care for a client with acute myeloid leukemia (AML) is to prevent:
- A. Cardiac arrhythmias.
- B. Liver failure.
- C. Renal failure.
- D. Hemorrhage.
Correct Answer: D
Rationale: AML causes pancytopenia, including thrombocytopenia, increasing the risk of hemorrhage. Preventing bleeding is a primary nursing goal through measures like avoiding invasive procedures and monitoring for bleeding signs. Arrhythmias, liver, and renal failure are less immediate concerns.
The nurse is planning to teach incisional care to a client before discharge. Which of the following instructions should be included?
- A. Do not touch your incision before your next appointment.
- B. Clean your incision three times a day with hydrogen peroxide and water.
- C. Do not be concerned about uneven lumps under the suture lines.
- D. If the staples don't come out by themselves before your next appointment, the surgeon will remove them.
Correct Answer: C
Rationale: Uneven lumps under suture lines are normal due to tissue healing and swelling. This reassurance prevents unnecessary worry. Hydrogen peroxide is not routinely recommended, and staples are typically removed by the surgeon.