Nokea
Following a classic cholecystectomy resection for multiple stones, the PACU nurse observes a serosanguious drainage on the dressing. The most appropriate intervention is to:
- A. notify the physician of the drainage.
- B. change the dressing.
- C. reinforce the dressing.
- D. apply an abdominal binder.
Correct Answer: C
Rationale: Serosanguious drainage is expected at this time. The dressing should be reinforced. Changing a new postop dressing increases the risk of infection. An abdominal binder interferes with visualization of the dressing.
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An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. inability to turn, cough, and breathe deeply
- B. inability to communicate pain
- C. inability to ambulate freely
- D. inability to use a bedside commode
Correct Answer: B
Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.
The LPN is checking for residual before administering enteral feeding through a PEG tube. Which of these steps is incorrect?
- A. The LPN elevates the head of the bed at least 30 degrees.
- B. If the residual is greater than 200 mL, the LPN should not administer the enteral feeding.
- C. The residual should be discarded prior to administering the tube feeding.
- D. The residual pH level is tested to ensure appropriate placement.
Correct Answer: C
Rationale: The residual should be injected back into the PEG tube, as it contains important enzymes and nutrients.
Which of the following statements is true about syphilis?
- A. The cause and mode of transmission is unclear
- B. There is no known cure for the disease
- C. When the primary lesion heals, the disease is cured
- D. Syphilis can be cured with a course of antibiotic therapy
Correct Answer: D
Rationale: Syphilis is an acute and chronic treponemal disease that can be cured with antibiotics, such as a single IM dose of long-acting penicillin G (benzathine penicillin) for primary, secondary, or early latent syphilis. The cause and transmission (sexual contact) are clear, and healing of the primary lesion does not indicate a cure without treatment.
The NA tells the nurse that the unit's small-adult BP cuff cannot be found and that the client's arm is too small to use a regular adult-sized cuff. Which direction should the nurse give to the NA?
- A. Document the other vital signs and note that the proper-fitting BP cuff is not available.
- B. Go to another nursing unit to obtain their small-adult BP cuff, and take the client's BP.
- C. Use the regular-sized BP cuff and add 10 to the diastolic and systolic BP readings.
- D. If the cuff closes around the arm, take the client's BP using the regular adult cuff.
Correct Answer: B
Rationale: B: A correct-sized cuff ensures accurate BP readings. A: Omitting BP is inappropriate. C: Adjusting readings is inaccurate. D: A too-large cuff gives falsely low readings.
The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
- C. You can lie down in about 30 minutes.
- D. You can lie down now.
Correct Answer: C
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure the medications are absorbed.