Nokea
Before undergoing a transsphenoidal hypophysectomy, the client asks the nurse how the surgeon will close the incision made in the dura. The nurse should respond based on the knowledge that:
- A. Dissolvable sutures are used to close the dura.
- B. Nasal packing provides pressure until normal wound healing occurs.
- C. A patch is made with a piece of fascia.
- D. A synthetic mesh is placed to facilitate healing.
Correct Answer: C
Rationale: A fascial patch is commonly used to repair the dura during transsphenoidal hypophysectomy to prevent CSF leaks.
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A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
- A. Count the rate to be sure that ventilations are deep enough to be sufficient.
- B. Notify the physician of the client's breathing pattern.
- C. Increase the rate of ventilations.
- D. Increase the tidal volume on the ventilator.
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
The nurse is assessing a client's nutritional status preoperatively. Which of the following observations would indicate poor nutrition in a 5-foot 7-inch female client who is 21 years of age?
- A. Poor posture.
- B. Little mass.
- C. Dull expression.
- D. Weight of 128 lb (58.1 kg).
Correct Answer: B
Rationale: Little mass in a 5'7' female suggests low body weight or muscle wasting, indicative of poor nutrition. A weight of 128 lb is within a healthy range, and poor posture or dull expression are less specific to nutritional status.
The nurse is supervising a newly hired nurse administer prescribed medications via a double-lumen nasogastric tube (NGT) with an air vent. Which action by the newly hired nurse requires follow-up?
- A. irrigates the air vent before medication administration with water.
- B. contacts the pharmacy to obtain available medications in liquid form.
- C. flushes the NGT between medications with water.
- D. administers each medication separately through the NGT.
Correct Answer: A
Rationale: The air vent of an NGT should not be irrigated, as it is for air passage, not medication or fluid administration.
What should the nurse monitor in a client receiving baclofen?
- A. Blood pressure.
- B. Spasticity levels.
- C. Blood glucose.
- D. Respiratory rate.
Correct Answer: B
Rationale: Spasticity levels are monitored to evaluate the effectiveness of baclofen in reducing muscle spasticity.
A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5°F (37.5°C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/µL. What should the nurse do first?
- A. Initiate an intake and output record.
- B. Place the client on bed rest.
- C. Place the client on contact isolation.
- D. Keep the client out of sunlight.
Correct Answer: B
Rationale: The client's symptoms (fatigue, bronze skin, dark urine, low hemoglobin, and RBC count) suggest hemolytic anemia, possibly due to an infectious or toxic exposure overseas. Placing the client on bed rest is the priority to reduce oxygen demand and prevent further hemolysis while diagnostic evaluation proceeds. Intake/output monitoring, isolation, and sunlight avoidance are not immediate priorities.