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An infant is at risk for an ileus after surgery to correct intussusception. Which observation should the nurse not include in an assessment for this complication?
- A. Measurement of urine specific gravity.
- B. Assessment of bowel sounds.
- C. Characteristics of the first stool.
- D. Measurement of gastric output.
Correct Answer: A
Rationale: Urine specific gravity is unrelated to assessing for ileus, which involves monitoring bowel sounds, stool characteristics, and gastric output to detect gastrointestinal function.
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A client has undergone a vaginal hysterectomy. Which interventions should the nurse include in the client's nursing care plan to decrease the risk of deep vein thrombosis or thrombophlebitis? Select all that apply.
- A. Use pneumatic compression boots.
- B. Maintain bed rest for 24 to 48 hours.
- C. Assist with range-of-motion leg exercises.
- D. Elevate the knees with the knee gatch on the bed.
- E. Remove antiembolism stockings twice daily for assessment.
Correct Answer: A,C,E
Rationale: The client is at risk for deep vein thrombosis or thrombophlebitis after this surgery, as for any other major surgery. For this reason, the nurse implements measures that will prevent this complication. Ambulation, pneumatic compression boots, range-of-motion exercises, and antiembolism stockings are all helpful. The nurse should avoid elevating the knees using the knee gatch in the bed, which inhibits venous return and places the client more at risk for deep vein thrombosis or thrombophlebitis.
The nurse is preparing to suction a tracheostomy for a client with methicillin resistant staphylococcus aureus (MRSA) (see fi gure). The nurse should:
- A. Wear a powered air purifying respirator (PAPR) face shield.
- B. Use goggles that include the hairline.
- C. Change to a surgical mask.
- D. Proceed to suction the client’s tracheostomy.
Correct Answer: D
Rationale: The nurse is wearing protective personnel equipment appropriately for suctioning the client: goggles, gown and respirator mask. It is not necessary to wear a powered air purifying respirator face shield to suction a tracheostomy. A surgical mask does not provide maximum protection.
The nurse is teaching a community group about violence in the family. Which statement by a group member about abusers would indicate a need for further teaching?
- A. They use fear and intimidation.
- B. They usually have poor self-esteem.
- C. They are often jealous or self-centered.
- D. They are more often from low-income families.
Correct Answer: D
Rationale: Personal characteristics of abusers include low self-esteem, immaturity, dependence, insecurity, and jealousy. The statement that abusers are more common among low-income families is inaccurate. The remaining options do describe characteristics of abusers who often use fear and intimidation to the point where their victims will do anything just to avoid further abuse.
A client with acquired immunodeficiency syndrome (AIDS) is admitted because of paranoia and visual hallucinations probably related to progressive dementia. The client continues to be restless and have hallucinations. The nurse calls the physician, and after explaining the situation, background, and assessment recommends that the physician consider writing an order to the client to have:
- A. Methylphenidate (Ritalin).
- B. Lorazepam (Ativan).
- C. Nefazodone (Serzone).
- D. Sertraline (Zoloft).
Correct Answer: B
Rationale: Lorazepam can help manage acute agitation and restlessness in a client with AIDS-related dementia.
The nurse is teaching a client with hypertension about dietary modifications. Which food should the nurse recommend limiting?
- A. Fresh fruits
- B. Lean proteins
- C. Canned soups
- D. Whole grains
Correct Answer: C
Rationale: Canned soups are high in sodium, which can exacerbate hypertension. Limiting sodium intake is a key dietary modification for blood pressure control.