Nokea
Following a gastrectomy, the nurse should position the client in which of the following positions?
- A. Prone.
- B. Supine.
- C. Right or left Sims.
- D. Fowler's.
Correct Answer: D
Rationale: Fowler's position (semi-upright) promotes lung expansion, reduces aspiration risk, and aids drainage post-gastrectomy. The other positions are less optimal for postoperative recovery.
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A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has:
- A. Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days
- B. Heart rate of 100 beats per minute after ambulating 200 feet
- C. Urine output of 2,000 mL in 24 hours
- D. Weakness and numbness in the lower extremities
Correct Answer: D
Rationale: Weakness and numbness in the lower extremities post-thoracoabdominal aneurysm repair suggest spinal cord ischemia or graft-related complications, requiring immediate reporting. Persistent pain, elevated heart rate post-ambulation, and normal urine output are expected or less urgent.
What should the nurse monitor in a client receiving baclofen?
- A. Blood pressure.
- B. Spasticity levels.
- C. Blood glucose.
- D. Respiratory rate.
Correct Answer: B
Rationale: Spasticity levels are monitored to evaluate the effectiveness of baclofen in reducing muscle spasticity.
A 62-year-old female is taking long-acting morphine 120 mg every 12 hours for pain from metastatic breast cancer. She can have 20 mg of immediate-release morphine every 3 to 4 hours as needed for breakthrough pain. The physician should be notified if the client uses more than how many breakthrough doses of morphine in 24 hours?
- A. Seven.
- B. Four.
- C. Two.
- D. One.
Correct Answer: B
Rationale: More than four breakthrough doses (80 mg additional morphine) in 24 hours indicates inadequate baseline pain control, requiring physician notification to adjust the long-acting morphine dose.
The client with glaucoma is scheduled for a hip replacement. Which of the following orders would require clarification before the nurse carries it out?
- A. Administer morphine sulfate.
- B. Administer atropine sulfate.
- C. Teach deep-breathing exercises.
- D. Teach leg lifts and muscle-setting exercises.
Correct Answer: B
Rationale: Atropine sulfate can increase intraocular pressure, which is contraindicated in glaucoma. The nurse should clarify this order to ensure it is safe for the client.
In preparing the client and the family for a postoperative stay in the intensive care unit (ICU) after open heart surgery, the nurse should explain that:
- A. The client will remain in the ICU for 5 days.
- B. The client will sleep most of the time while in the ICU.
- C. Noise and activity within the ICU are minimal.
- D. The client will receive medication to relieve pain.
Correct Answer: D
Rationale: Pain management is a priority post-open heart surgery, and clients receive medications to ensure comfort in the ICU.