Nokea
During the postoperative period, the client who underwent a pelvic exenteration reports pain in the calf area. What action should the nurse take?
- A. Ask the client to walk and observe the gait.
- B. Lightly massage the calf area to relieve the pain.
- C. Check the calf area for temperature, color, and size.
- D. Administer PRN morphine sulfate as prescribed for postoperative pain.
Correct Answer: C
Rationale: The nurse monitors the postoperative client for complications such as deep vein thrombosis, pulmonary emboli, and wound infection. Pain in the calf area could indicate a deep vein thrombosis. Change in color, temperature, or size of the client's calf could also indicate this complication. Options 1 and 2 could result in an embolus if in fact the client had a deep vein thrombosis. Administering pain medication for this client is not the appropriate nursing action since further assessment needs to take place.
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A client receiving total parenteral nutrition (TPN) through a subclavian catheter suddenly develops dyspnea, tachycardia, cyanosis, and decreased level of consciousness. Based on these findings, which is the best intervention for the nurse to implement for the client?
- A. Obtain a stat oxygen saturation level.
- B. Examine the insertion site for redness.
- C. Perform a stat finger-stick glucose level.
- D. Turn the client to the left side in Trendelenburg's position.
Correct Answer: D
Rationale: Clinical indicators of air embolism include chest pain, tachycardia, dyspnea, anxiety, feelings of impending doom, cyanosis, and hypotension. Positioning the client in Trendelenburg's and on the left side helps isolate the air embolism in the right atrium and prevents a thromboembolic event in a vital organ.
The nurse has developed a plan of care for a client with a diagnosis of anterior cord syndrome. Which intervention should the nurse include in the plan of care to minimize the client's long-term risk for injury?
- A. Change the client's positions slowly.
- B. Assess the client for decreased sensation to touch.
- C. Assess the client for decreased sensation to vibration.
- D. Teach the client about loss of motor function and decreased pain sensation.
Correct Answer: D
Rationale: Anterior cord syndrome is caused by damage to the anterior portion of the gray and white matter. Clinical findings related to anterior cord syndrome include loss of motor function, temperature sensation, and pain sensation below the level of injury. The syndrome does not affect sensations of fine touch, position, and vibration.
A client is scheduled to have a percutaneous transluminal coronary angioplasty (PTCA). What information about the balloon-tipped catheter should nurse plan to include when providing client education concerning the procedure?
- A. A mesh-like device within the catheter will be inflated causing it to spring open.
- B. The catheter will be used to compress the plaque against the coronary blood vessel wall.
- C. The catheter will cut away the plaque from the coronary vessel wall using an embedded blade.
- D. The catheter will be positioned in a coronary artery to take pressure measurements in the vessel.
Correct Answer: B
Rationale: In PTCA, a balloon-tipped catheter is used to compress the plaque against the coronary blood vessel wall. Option 1 describes placement of a coronary stent, option 3 describes coronary atherectomy, and option 4 describes part of the process used in cardiac catheterization.
While providing care to a client with a head injury, the nurse notes that a client exhibits this posture (refer to figure). What should the nurse document that the client is exhibiting?
- A. Flaccidity
- B. Decorticate posturing
- C. Decerebrate posturing
- D. Rigidity in the upper extremities
Correct Answer: B
Rationale: Decortication is abnormal posturing seen in the client with lesions that interrupt the corticospinal pathways. In this posturing, the client's arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the feet and legs extended. Flaccidity indicates weak, soft, and flabby muscles that lack normal muscle tone. Decerebration is abnormal posturing and rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos. Decerebration is usually associated with dysfunction in the brainstem area. Rigidity indicates hardness, stiffness, or inflexibility. Decerebrate posturing is associated with rigidity.
When caring for a client diagnosed with myasthenia gravis, the nurse should be alert for which manifestations of myasthenic crisis? Select all that apply.
- A. Bradycardia
- B. Increased diaphoresis
- C. Decreased lacrimation
- D. Bowel and bladder incontinence
- E. Absent cough and swallow reflex
- F. Sudden marked rise in blood pressure
Correct Answer: B,D,E,F
Rationale: Myasthenic crisis is caused by undermedication or can be precipitated by an infection or sudden withdrawal of anticholinesterase medications. It may also occur spontaneously. Clinical manifestations include increased diaphoresis, bowel and bladder incontinence, absent cough and swallow reflex, sudden marked rise in blood pressure because of hypoxia, increased heart rate, severe respiratory distress and cyanosis, increased secretions, increased lacrimation, restlessness, and dysarthria.