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After receiving report, which client should the nurse assess last?
- A. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac
- B. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed
- C. An older client with a distended abdomen and no drainage from the nasogastric tube
- D. An adult client with rectal tube draining clear pale red liquid drainage
Correct Answer: D
Rationale: The correct answer is D because the client with rectal tube drainage of clear pale red liquid is likely to be the least urgent since this is a normal post-operative finding. Clear pale red liquid drainage from a rectal tube is typically not a cause for immediate concern. Choices A, B, and C present clients with concerning signs that may require more immediate assessment and intervention. A client with dark red drainage on a postoperative dressing may indicate active bleeding, a client with a compressed Jackson-Pratt drain bulb may have inadequate drainage resulting in complications, and a client with a distended abdomen and no drainage from the nasogastric tube may be experiencing gastrointestinal issues that need prompt evaluation.
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Two weeks following a Billroth II (gastrojejunostomy), a client develops nausea, diarrhea, and diaphoresis after every meal. When the nurse develops a teaching plan for this client, which expected outcome statement is the most relevant?
- A. Describes a schedule for antacid use in combination with other prescribed medications
- B. Selects a pattern of small meals interspersed with fluid intake
- C. Commits to engaging in a variety of stress reduction techniques
- D. Expresses a commitment to decrease nicotine intake
Correct Answer: B
Rationale: The symptoms described are indicative of dumping syndrome, a common complication following a Billroth II procedure. Dumping syndrome presents with symptoms such as nausea, diarrhea, and diaphoresis after meals. To manage these symptoms effectively, the client should opt for small, frequent meals and avoid consuming fluids along with meals. Choice A is inaccurate because antacid use does not directly address the symptoms of dumping syndrome. Choice C is irrelevant as stress reduction techniques are not the primary intervention for dumping syndrome. Choice D is unrelated to the symptoms experienced by the client, making it an inappropriate choice.
When implementing a disaster intervention plan, which intervention should the nurse implement first?
- A. Initiate the discharge of stable clients from hospital units
- B. Identify a command center where activities are coordinated
- C. Assess community safety needs impacted by the disaster
- D. Instruct all essential off-duty personnel to report to the facility
Correct Answer: B
Rationale: When implementing a disaster intervention plan, the first step the nurse should take is to identify a command center where activities are coordinated. This step is crucial for ensuring an organized and effective disaster response. Option A, initiating the discharge of stable clients, is not a priority during the initial phase of disaster response. Option C, assessing community safety needs, usually follows setting up a command center. Option D, instructing off-duty personnel to report, may be necessary but is not the primary intervention at the beginning of a disaster situation.
A client who will be going to surgery states no known allergies to any medications. What is the most important nursing action for the nurse to implement next?
- A. Assess client's knowledge of an allergic response
- B. Record 'no known drug allergies' on the preoperative checklist
- C. Flag 'no known drug allergies' on the front of the chart
- D. Assess client's allergies to non-drug substances
Correct Answer: B
Rationale: The most important action to take in this situation is to record 'no known drug allergies' on the preoperative checklist. This ensures that all healthcare staff involved in the surgery are aware of the client's stated lack of drug allergies, helping to prevent any potential adverse reactions. Assessing the client's knowledge of an allergic response (Choice A) may be valuable but is not the most crucial action at this point. Flagging 'no known drug allergies' on the front of the chart (Choice C) is less practical and visible compared to documenting it on the preoperative checklist. Assessing the client's allergies to non-drug substances (Choice D) is not the priority in this scenario where the focus is on medications due to the upcoming surgery.
A client collapses while showering and is found by the nurse while making rounds. The client is not breathing and does not have a palpable pulse. The nurse obtains the Automated External Defibrillator (AED). What action should the nurse implement next?
- A. Follow the prompts of the AED
- B. Apply the AED pads to the client's chest
- C. Wipe the client's chest dry
- D. Move the client from the bathroom
Correct Answer: B
Rationale: Applying the AED pads is the immediate next step after obtaining the AED in a cardiac arrest situation. Placing the pads correctly on the client's chest is crucial for the AED to analyze the heart rhythm accurately and deliver a shock if needed. Following the prompts of the AED comes after the pads are in place. Wiping the client's chest dry or moving the client from the bathroom are not priorities at this critical moment and may delay life-saving interventions.
An adolescent male client is admitted to the hospital. Based on Erikson's theory of psychosocial development, which nursing intervention best assists this adolescent's adjustment to his hospital stay?
- A. Invite him to participate in the evening group activity
- B. Schedule frequent private phone calls to his parents
- C. Provide access to a variety of video games in his room
- D. Encourage him to learn his way around the hospital
Correct Answer: A
Rationale: Inviting the adolescent to participate in group activities aligns with Erikson's theory of psychosocial development, specifically the stage of developing social relationships. By engaging in group activities, the adolescent can interact with peers, fostering social skills and aiding in adjustment to the hospital environment.
Choice B is incorrect as excessive reliance on phone calls to parents may hinder the adolescent's autonomy and independence, which are crucial aspects of Erikson's theory for this age group. Choice C, providing access to video games, while potentially offering entertainment, does not directly address the need for social interaction and relationship-building. Choice D, encouraging the adolescent to learn his way around the hospital, is important for familiarity but may not directly address the need for social interaction and adjustment in the hospital setting.