Nokea
During preadmission testing for same-day surgery, a client states that she has added two cloves of garlic each day to her diet to help control her blood pressure. The nurse should further inquire about which of the following?
- A. The type of surgery the client is having.
- B. What her blood pressure has been running.
- C. The amount of garlic she is eating.
- D. Her preference for the type of anesthesia.
Correct Answer: B
Rationale: Garlic can affect blood pressure and has anticoagulant properties, which may increase bleeding risk during surgery. Inquiring about the client's blood pressure helps assess the impact of garlic on her condition and informs surgical planning. The type of surgery, amount of garlic, or anesthesia preference are less directly relevant to this concern.
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The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
- A. Remove the drain from the incision.
- B. Notify the surgeon.
- C. Empty drainage.
- D. Record the amount in the unit as output on the client's chart.
Correct Answer: C
Rationale: A full portable wound suction unit (e.g., Jackson-Pratt) should be emptied to maintain suction and prevent complications. The drainage is then measured and recorded.
The nurse is teaching an older adult client with a history of heat exhaustion. Which of the following statements by the client indicates a need for further teaching?
- A. I should take a cool shower after being outdoors in very hot weather.
- B. I can place ice packs on my neck, chest, and stomach after being outdoors in the heat.
- C. I should wear lightweight, light-colored, and loose-fitting clothing when working outside on very hot days.
- D. I should consume water and take my salt tablets when I am outside gardening on very hot days.
Correct Answer: B
Rationale: Using ice packs can cause vasoconstriction or tissue damage and is not recommended for heat exhaustion. Cool showers (A), appropriate clothing (C), and hydration (D) are correct, but salt tablets are unnecessary with adequate diet and hydration.
The nurse is discharging a client who is prescribed antitubercular medications for pulmonary tuberculosis. The nurse is concerned about an adverse reaction to the medications if the client
- A. lives with a roommate and works as a flight attendant.
- B. has an implanted hormonal intrauterine device (IUD).
- C. smokes one pack of cigarettes per day.
- D. drinks three glasses of red wine each day.
Correct Answer: D
Rationale: Alcohol consumption, such as drinking three glasses of red wine daily, increases the risk of hepatotoxicity when taking antitubercular medications like isoniazid and rifampin, which are metabolized by the liver. Choice A is irrelevant to medication reactions, though it may pose a transmission risk. Choice B (IUD) and Choice C (smoking) do not directly interact with antitubercular medications to cause adverse reactions.
The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent.
- A. Unlike reflux into the stoma.
- B. Appliance separation.
- C. Urine leakage.
- D. The need to restrict fluids.
Correct Answer: C
Rationale: A night collection bag prevents urine leakage by providing adequate capacity, reducing the risk of appliance overflow during sleep.
The nurse asks the client to state her name as soon as she regains consciousness postoperatively after a subtotal thyroidectomy and at each assessment. The nurse does this to monitor for signs of which of the following?
- A. External hemorrhage.
- B. Decreasing level of consciousness.
- C. Laryngeal nerve damage.
- D. Upper airway obstruction.
Correct Answer: C
Rationale: Asking the client to speak monitors for laryngeal nerve damage, which can cause vocal cord paralysis and hoarseness, a potential complication of thyroidectomy.