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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Which arterial blood gas (ABG) values should the nurse anticipate in the client with a nasogastric tube attached to continuous suction?
- A. pH 7.25, PaCO2 55, HCO3 24
- B. pH 7.30, PaCO2 38, HCO3 20
- C. pH 7.48, PaCO2 30, HCO3 23
- D. pH 7.49, PaCO2 38, HCO3 30
Correct Answer: D
Rationale: Continuous nasogastric suction can lead to metabolic alkalosis due to the loss of gastric acid (hydrochloric acid), which reduces hydrogen ions and increases bicarbonate levels. The ABG values in option 4 (pH 7.49, PaCO2 38, HCO3 30) indicate metabolic alkalosis, with an elevated pH and high bicarbonate level, consistent with this condition. Option 1 suggests respiratory acidosis, option 2 suggests metabolic acidosis, and option 3 suggests respiratory alkalosis, none of which align with the expected acid-base imbalance from nasogastric suction.
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 a client with a chest injury is suspected of experiencing a pleural effusion, which typical manifestations of this respiratory problem should the nurse assess for? Select all that apply.
- A. Dry cough
- B. Moist cough
- C. Dyspnea at rest
- D. Productive cough
- E. Dyspnea on exertion
- F. Nonproductive cough
Correct Answer: A,E,F
Rationale: A pleural effusion is the collection of fluid in the pleural space. Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.
The nurse providing diet teaching to a client experiencing heart failure instructs the client to avoid which food item?
- A. Sherbet
- B. Steak sauce
- C. Apple juice
- D. Leafy green vegetables
Correct Answer: B
Rationale: Steak sauce is high in sodium. Leafy green vegetables, any juice (except tomato or V8 brand vegetable), and sherbet are all low in sodium. Clients with heart failure should monitor sodium intake.
A client who has sustained a neck injury is unresponsive and pulseless. What should the emergency department nurse do to open the client's airway?
- A. Insert oropharyngeal airway.
- B. Tilt the head and lift the chin.
- C. Place in the recovery position.
- D. Stabilize the skull and push up the jaw.
Correct Answer: D
Rationale: The health care team uses the jaw-thrust maneuver to open the airway until a radiograph confirms that the client's cervical spine is stable to avoid potential aggravation of a cervical spine injury. Options 1 and 2 require manipulation of the spine to open the airway, and option 3 can be ineffective for opening the airway.