Nokea
Following a gastric resection, a 70-year-old client is admitted to the postanesthesia care unit. He was extubated prior to leaving the suite. On arrival at the postanesthesia care unit, the nurse should:
- A. Check airway, feeling for amount of air exchange noting rate, depth, and quality of respirations
- B. Obtain pulse and blood pressure readings noting rate and quality of pulse
- C. Reassure the client that his surgery is over and that he is in the recovery room
- D. Review physician's orders, administering medications as ordered
Correct Answer: A
Rationale: Adequate air exchange and tissue oxygenation depend on competent respiratory function. Checking the airway is the nurse's priority action. Obtaining the vital signs is an important action, but it is secondary to airway management. Reorienting a client to time, place, and person after surgery is important, but it is secondary to airway and vital signs. Airway management takes precedence over physician's orders unless they specifically relate to airway management.
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The nurse is caring for a client with a history of heart failure. Which discharge instruction is most important?
- A. Weigh yourself daily.'
- B. Limit exercise to 10 minutes daily.'
- C. Increase sodium intake.'
- D. Take over-the-counter pain relievers as needed.'
Correct Answer: A
Rationale: Daily weight monitoring detects fluid retention early in heart failure, allowing timely intervention. Exercise should be moderate, sodium restricted, and pain relievers used cautiously.
The nurse is caring for a client with osteoporosis who is being discharged on alendronate (Fosamax). Which statement would indicate a need for further teaching?
- A. "I should take the medication immediately before bedtime every night."
- B. "I should remain in an upright position for 30 minutes after taking Fosamax."
- C. "The medication should be taken by mouth with water."
- D. "I should not have any food with this medication."
Correct Answer: A
Rationale: Alendronate should be taken in the morning on an empty stomach, not before bedtime (A), indicating a need for further teaching. Upright positioning (B), taking with water (C), and avoiding food (D) are correct.
The nurse is caring for a client with a history of preterm labor. Which medication is most likely to be ordered to halt preterm contractions?
- A. Magnesium sulfate
- B. Nifedipine
- C. Ritodrine
- D. Indomethacin
Correct Answer: B
Rationale: Nifedipine a calcium channel blocker is commonly used as a tocolytic to halt preterm contractions by relaxing uterine smooth muscle. Ritodrine is less used due to side effects magnesium sulfate is more for preeclampsia and indomethacin is used in specific cases.
A 16-year-old client comes to the prenatal clinic for her monthly appointment. She has gained 14 lb from her 7th to 8th month; her face and hands indicate edema. She is diagnosed as having PIH and referred to the high-risk prenatal clinic. The client's weight increase is most likely due to:
- A. Overeating and subsequent obesity
- B. Obesity prior to conception
- C. Hypertension due to kidney lesions
- D. Fluid retention
Correct Answer: D
Rationale: Overeating can lead to obesity, but not to edema. There is no indication of obesity prior to pregnancy. PIH is more prevalent in the underweight than in the obese in this age group. Hypertension can be due to kidney lesions, but it would have been apparent earlier in the pregnancy. The weight gain in PIH is due to the retention of sodium ions and fluid and is one of the three cardinal symptoms of PIH.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. The ability to see another's point of view increases.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusion.
Correct Answer: C
Rationale: Piaget's concrete operations stage (ages 7-11) involves logical, coherent thinking about concrete events, not abstract concepts. Perspective-taking improves but is secondary to logical thought.