Nokea
During a follow-up visit 2 weeks after pneumonectomy, the client reports numbness and tenderness at the surgical site. Which statement should the nurse make to accurately address the client's concerns?
- A. This is not likely to be permanent, but may last for some months.
- B. You are having a severe problem and will probably be rehospitalized
- C. This is probably caused by permanent nerve damage as a result of surgery.
- D. This is often the first sign of a wound infection; I will check your temperature.
Correct Answer: A
Rationale: Clients who undergo pneumonectomy or other surgical procedures may experience numbness, altered sensation, or tenderness in the area that surrounds the incision. These sensations may last for months. It is not considered to be a severe problem and is not indicative of a wound infection.
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The nurse performing a prenatal assessment on a client in the first trimester of pregnancy discovers that the client frequently consumes beverages containing alcohol. Why should the nurse initiate interventions immediately to assist the client in avoiding alcohol consumption?
- A. To reduce the potential for fetal growth restriction in utero
- B. To promote the normal psychosocial adaptation of the mother to pregnancy
- C. To minimize the potential for placental abruptions during the intrapartum period
- D. To reduce the risk of teratogenic effects to embryo's developing fetal organs and tissue
Correct Answer: D
Rationale: Alcohol consumption during the first trimester poses a significant risk for teratogenic effects, as this is a critical period for organogenesis in the developing embryo. Exposure to alcohol can lead to fetal alcohol syndrome or other congenital anomalies, making immediate intervention essential to protect fetal development. While fetal growth restriction, psychosocial adaptation, and placental abruption are concerns, they are less directly associated with early pregnancy alcohol exposure compared to teratogenic effects.
A client receiving total parenteral nutrition (TPN) via a central venous catheter (CVC) is scheduled to receive an intravenous (IV) antibiotic. Which intervention should the nurse implement before administering the antibiotic?
- A. Turn off the TPN for 30 minutes.
- B. Ensure a separate IV access route.
- C. Flush the CVC with normal saline.
- D. Check for compatibility with TPN.
Correct Answer: B
Rationale: The TPN line is used only for the administration of the TPN solution to prevent crystallization in the CVC tubing and disruption of the TPN infusion. Any other IV medication must be administered through a separate IV access site, including a separate infusion port of the CVC catheter. Therefore, options 1, 3, and 4 are incorrect actions.
The nurse is preparing to initiate an intravenous nitroglycerin drip on a client who has experienced an acute myocardial infarction. In the absence of an invasive (arterial) monitoring line, the nurse prepares to have which piece of equipment for use at the bedside to help assure the client's safety?
- A. Defibrillator
- B. Pulse oximeter
- C. Central venous pressure (CVP) tray
- D. Noninvasive blood pressure monitor
Correct Answer: D
Rationale: Nitroglycerin dilates arteries and veins (vasodilator), causing peripheral blood pooling, thus reducing preload, afterload, and myocardial workload. This action accounts for the primary side effect of nitroglycerin, which is hypotension. In the absence of an arterial monitoring line, the nurse should have a noninvasive blood pressure monitor for use at the bedside.
An adolescent is admitted to the orthopedic nursing unit after spinal rod insertion for the treatment of scoliosis. Which assessments are most important in the immediate postoperative period when considering the client's neurovascular status? Select all that apply.
- A. Pain level
- B. Urinary output
- C. Ability to move all extremities
- D. Capillary refill in all extremities
- E. Ability to flex and extend the feet
- F. Ability to detect sensations in all extremities
Correct Answer: C,D,E,F
Rationale: When the spinal column is manipulated during surgery, altered neurovascular status is a possible complication; therefore, neurovascular checks, including circulation, sensation, and motion, should be done at least every 2 hours. Level of pain and urinary output are important postoperative assessments, but neurovascular status is more important.
The nurse instructing a client with chronic pancreatitis about measures to prevent its exacerbation should provide which information? Select all that apply.
- A. Eat bland foods.
- B. Avoid alcohol ingestion.
- C. Avoid cigarette smoking.
- D. Avoid caffeinated beverages.
- E. Eat small meals and snacks high in calories.
- F. Eat high-fat, low-protein, high-carbohydrate meals.
Correct Answer: A,B,C,D,E
Rationale: Chronic pancreatitis is a progressive, destructive disease of the pancreas, characterized by remissions and exacerbations (recurrence). Measures to prevent an exacerbation include eating bland, low-fat, high-protein, moderate-carbohydrate meals; avoiding alcohol ingestion, nicotine, and caffeinated beverages; eating small meals and snacks high in calories; and avoiding gastric stimulants such as spices.