Nokea
During the preoperative interview, the nurse obtains information about the client's medication history. Which of the following is not necessary to record about the client?
- A. Current use of medications, herbs, and vitamins.
- B. Over-the-counter medication use in the last 6 weeks.
- C. Steroid use in the last year.
- D. Use of all drugs taken in the last 18 months.
Correct Answer: D
Rationale: Recording all drugs taken in the last 18 months is excessive, as many may no longer be relevant to surgical risks. Current medications, recent over-the-counter drugs, and steroid use are critical due to their potential impact on surgery.
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A client has returned from surgery during which her jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed nursing personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the UAP?
- A. Keep the client in a side-lying position with the head slightly elevated.
- B. Do not reposition the client without the assistance of a registered nurse.
- C. The client can assume any position that is comfortable.
- D. Keep the client's head elevated on two pillows at all times.
Correct Answer: A
Rationale: A side-lying position with the head slightly elevated helps prevent aspiration and maintains airway patency in a client with wired jaws. The other options are either overly restrictive, unsafe, or not optimal for airway management.
The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan?
- A. Food intake
- B. Fluid volume
- C. Skin integrity
- D. Tissue perfusion
Correct Answer: D
Rationale: Post-AAA repair, tissue perfusion is critical to ensure graft patency and prevent ischemia in the lower extremities or organs. Teaching should emphasize signs of poor perfusion (e.g., pain, pallor, pulselessness) and follow-up care. Food, fluid, and skin integrity are less urgent.
The nurse notes that the daily white blood cell (WBC) count in a client with aplastic anemia has dropped overnight from 3,900 to 2,900/µL. Which is the appropriate nursing intervention?
- A. Continue monitoring the client.
- B. Call the laboratory to verify the report.
- C. Document the finding.
- D. Call the physician and place the client in reverse isolation.
Correct Answer: D
Rationale: A significant drop in WBC count (3,900 to 2,900/µL) in aplastic anemia indicates worsening neutropenia, increasing infection risk. The nurse should notify the physician and place the client in reverse isolation to protect against infections. Monitoring, verifying, or documenting alone are insufficient given the urgency.
The nurse is preparing to administer an intradermal injection. Which of the following would be appropriate action by the nurse?
- A. Displace the skin to the side and inject at a 15 degree angle
- B. Position the needle bevel up at 15 degrees
- C. Position the needle bevel up at 45 degrees
- D. Position the needle bevel up at 90 degrees with a dart-like motion
Correct Answer: B
Rationale: Intradermal injections require a 15-degree angle with the bevel up to ensure shallow administration.
The nurse has provided medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply.
- A. I may still need pain medication while this patch is applied.
- B. If the patch comes loose, I may reinforce it with a piece of tape.
- C. I can apply heat to the patch site to increase the pain relief.
- D. I should remove this patch while I am sleeping.
- E. The patch will need to be changed every 72 hours.
Correct Answer: A,B,E
Rationale: A: Breakthrough pain may require additional medication. B: Taping a loose patch is acceptable. E: Fentanyl patches are typically changed every 72 hours. C is incorrect because heat can increase absorption and risk toxicity. D is incorrect as patches are not removed during sleep.