Nokea
Home-care instructions for the child following a cardiac catheterization should include:
- A. Notify the physician if a slight bruise develops around the insertion site.
- B. Use sponge bathing until stitches are removed.
- C. Give aspirin if the child complains of pain at the insertion site.
- D. Keep a clean, dry dressing on the insertion site for 2 days.
Correct Answer: B
Rationale: A small bruise may develop around the insertion site and is not a reason for alarm. It is best to keep the child out of the bathtub until the sutures are removed. Acetaminophen, not aspirin, is the drug of choice if there is pain at the insertion site. The insertion site should be kept clean and dry and open to air.
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A client has had a unilateral adrenalectomy to remove a tumor. The most important measurement in the immediate post-operative period for the nurse to take is:
- A. The blood pressure
- B. The temperature
- C. The urinary output
- D. The specific gravity of the urine
Correct Answer: A
Rationale: Adrenalectomy can disrupt cortisol and aldosterone production leading to blood pressure instability (e.g. hypotension from adrenal insufficiency). Monitoring blood pressure is critical to detect and manage these changes promptly.
While obtaining information about the client's current medication use, the nurse learns that the client takes ginkgo to improve mental alertness. The nurse should tell the client to:
- A. Report signs of bruising or bleeding to the doctor.
- B. Avoid sun exposure while using the herbal supplement.
- C. Purchase only those brands with FDA approval.
- D. Increase daily intake of vitamin E.
Correct Answer: A
Rationale: Ginkgo can increase bleeding risk by inhibiting platelet aggregation, so clients should report signs of bruising or bleeding to their doctor.
The nurse is caring for a client with a closed head injury. Which intervention is most important to prevent increased intracranial pressure (ICP)?
- A. Keep the head of the bed elevated 30–45 degrees.
- B. Administer acetaminophen for headache.
- C. Provide frequent oral care.
- D. Encourage deep breathing exercises.
Correct Answer: A
Rationale: Elevating the head of the bed 30–45 degrees promotes venous drainage, reducing ICP. Acetaminophen (B), oral care (C), and breathing exercises (D) are supportive but less critical for ICP control.
The client has elected to have epidural anesthesia to relieve labor pain. If the client experiences hypotension,the nurse should:
- A. Place her in Trendelenburg position
- B. Decrease the rate of the IV infusion
- C. Administer oxygen via nasal cannula
- D. Increase the rate of the IV infusion
Correct Answer: D
Rationale: Hypotension from epidural anesthesia results from vasodilation. Increasing the IV infusion rate (e.g. with saline) restores blood volume and pressure. Trendelenburg may worsen spinal anesthesia spread and oxygen is secondary unless hypoxia occurs.
The nurse is caring for a client with a history of a fractured humerus who is in a sling. The nurse should:
- A. Apply ice to the fracture site
- B. Encourage active range of motion
- C. Keep the arm in a dependent position
- D. Massage the arm daily
Correct Answer: A
Rationale: Ice reduces swelling and pain at the fracture site. Active motion is limited, dependent positioning increases swelling, and massage is not recommended.