Nokea
Because of steroid excess after a bilateral adrenalectomy, the nurse should assess the client for:
- A. Postoperative confusion.
- B. Delayed wound healing.
- C. Emboli.
- D. Malnutrition.
Correct Answer: B
Rationale: Excess steroids, even post-adrenalectomy, can cause delayed wound healing due to their catabolic effects.
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A client is to receive enoxaparin (Lovenox) 6 hours before the scheduled time of her laparoscopic vaginal assisted hysterectomy. Which of the following effects does the nurse recognize as an intended therapeutic action of the enoxaparin?
- A. Increase in red blood cell production.
- B. Reduction of postoperative thrombi.
- C. Decrease in postoperative bleeding.
- D. Promotion of tissue healing.
Correct Answer: B
Rationale: Enoxaparin is an anticoagulant that prevents postoperative thrombi by inhibiting clot formation, reducing the risk of deep vein thrombosis or pulmonary embolism.
What should the nurse include in the care plan for a client with dysphagia?
- A. Offer thin liquids.
- B. Use a chin-tuck maneuver.
- C. Provide a low-fiber diet.
- D. Encourage rapid eating.
Correct Answer: B
Rationale: The chin-tuck maneuver reduces aspiration risk in clients with dysphagia.
Peripheral blood flow is dependent on which of the following variables?
- A. Blood viscosity and diameter of vessels
- B. Diameter and resistance of vessels
- C. Force of contraction of the heart and resistance of vessels
- D. Pressure differences in the arterial and venous systems and resistance
Correct Answer: D
Rationale: Peripheral blood flow depends on pressure differences between the arterial and venous systems (driving force) and vascular resistance (opposing force). This relationship is governed by Poiseuille's law and Ohm's law for fluid flow, where flow is proportional to the pressure gradient and inversely proportional to resistance. The other options are incomplete or incorrect combinations of factors.
A nurse is assessing a client with a urinary tract infection who takes an antihypertensive drug. The nurse reviews the client’s urinalysis results (see chart). The nurse should:
- A. Encourage the client to increase fl uid intake.
- B. Withhold the next dose of antihypertensive medication.
- C. Restrict the client’s sodium intake.
- D. Encourage the client to eat at least half of a banana per day
Correct Answer: A
Rationale: The client’s urine specifi c gravity is elevated. Specific gravity is a refl ection of the concentrating ability of the kidneys. This level indicates that the urine is concentrated. By increasing fluid intake, the urine will become more dilute. Antihypertensives do not make urine more concentrated unless there is a diuretic component within them. The nurse should not hold a dose of antihypertensive medication. Sodium tends to pull water with it; by restricting sodium, less water, not more, will be present. Bananas do not aid in the dilution of urine.
Which activity should the nurse encourage the client to avoid when there is a risk for increased intracranial pressure (ICP)?
- A. Deep breathing.
- B. Turning.
- C. Coughing.
- D. Passive range-of-motion (ROM) exercises.
Correct Answer: C
Rationale: Coughing increases intrathoracic pressure, which can elevate ICP. Deep breathing, turning, and passive ROM are generally safe and may even help prevent complications like atelectasis or contractures if done gently.