Nokea
Mr. K is admitted to the orthopedic unit one morning in preparation for a total knee replacement to start in two hours. Which of the following is a priority topic to instruct this client on admission?
- A. The approximate length of the surgery
- B. The type of anticoagulants that will be prescribed
- C. The time of the next meal of solid food
- D. The length of time until the client can return to work
Correct Answer: A
Rationale: The priority topic to instruct a client admitted for a total knee replacement surgery should be the approximate length of the surgery. Pre-surgical teaching should focus on preparing the client for the upcoming procedure. Providing information about the duration of the surgery can help manage the client's expectations, reduce anxiety, and ensure they are mentally prepared for the operation. While details about post-operative care, anticoagulants, meals, and return to work are important, they are not the immediate priority during the preoperative phase. These aspects can be addressed at a later stage in the client's care journey.
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The nurse is assessing an infant with developmental dysplasia of the hip. Which finding would the nurse anticipate?
- A. Unequal leg length
- B. Limited adduction
- C. Diminished femoral pulses
- D. Symmetrical gluteal folds
Correct Answer: A
Rationale: The correct answer is 'Unequal leg length.' Shortening of a leg is a common sign of developmental dysplasia of the hip. Limited adduction (Choice B) may be present but is less specific to developmental dysplasia of the hip. Diminished femoral pulses (Choice C) are not typically associated with developmental dysplasia of the hip. Symmetrical gluteal folds (Choice D) are a normal finding and would not be expected in a patient with developmental dysplasia of the hip.
A nurse is performing an end-of-shift count of narcotics kept in the locked cabinet. The narcotic log states there should be 26 oxycodone pills left, but there are only 24 in the drawer. What is the first action of the nurse?
- A. Perform the count again
- B. Contact the pharmacy to determine if the narcotic log is incorrect
- C. Check with the last nurse to sign out narcotics from the system
- D. Notify the house supervisor that narcotic medications are missing
Correct Answer: A
Rationale: The first action the nurse should take in this situation is to perform the count again. This step is crucial to ensure there was no miscount during the initial check. By verifying the count, the nurse can confirm if there is indeed a discrepancy in the number of oxycodone pills. Contacting the pharmacy, checking with the last nurse, or notifying the house supervisor should only be considered after ensuring the count is accurate. It's important to rule out any human error before escalating the issue to others.
Which of the following is the most appropriate example of anticipatory guidance for a 16-year-old who has been hospitalized for an ankle fracture?
- A. Changes associated with puberty
- B. Driving and staying safe
- C. The health hazards of smoking
- D. Social media influences
Correct Answer: B
Rationale: Anticipatory guidance is an educational process that provides information important to a client's situation. When considering a 16-year-old who has been hospitalized for an ankle fracture, the most suitable anticipatory guidance would be regarding driving and staying safe. This guidance is crucial as it is age-appropriate and relevant to preventing future injuries. Choices A, C, and D are less pertinent in this scenario. Changes associated with puberty, health hazards of smoking, and social media influences may not directly address the immediate safety concerns of a 16-year-old with an ankle fracture.
What question must the nurse ask when formulating a nursing diagnosis?
- A. What diagnosis did the physician make for this client?
- B. What is the issue that I can solve for this client?
- C. What physician orders will resolve this issue?
- D. What underlying disease does this client have?
Correct Answer: B
Rationale: When formulating a nursing diagnosis, the nurse should focus on identifying the client's specific health problems that can be addressed through nursing interventions. The correct answer emphasizes the nurse's role in identifying and addressing client-specific issues through nursing care. Choice A is incorrect because nursing diagnoses are distinct from medical diagnoses made by physicians. Choice C is incorrect as it focuses on physician orders rather than the nurse's role in diagnosing and addressing client problems. Choice D is incorrect because it pertains to identifying underlying diseases, which is not the primary focus of nursing diagnoses.
A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?
- A. Knowledge Deficit related to post-partum blood loss
- B. Self-Care Deficit related to post-partum neglect
- C. Fluid Volume Deficit related to post-partum hemorrhage
- D. Body Image Disturbance related to body changes after delivery
Correct Answer: C
Rationale: The correct nursing diagnosis in this situation is 'Fluid Volume Deficit related to post-partum hemorrhage.' Post-partum hemorrhage can lead to excessive bleeding, putting the client at risk of fluid volume deficit due to the loss of blood volume. This diagnosis is most appropriate as it addresses the immediate concern of fluid loss. 'Knowledge Deficit related to post-partum blood loss' (Choice A) is incorrect as the priority in this case is addressing the physical issue of fluid volume deficit rather than knowledge deficit. 'Self-Care Deficit related to post-partum neglect' (Choice B) is not relevant to the situation described. 'Body Image Disturbance related to body changes after delivery' (Choice D) is not the most appropriate nursing diagnosis in this context where the primary concern is fluid volume deficit due to post-partum hemorrhage.