Nokea
A client one day after a thoracotomy.
Nursing actions on the care plan include: turn, cough, and deep breathe q2h. The nurse understands that the purpose of this nursing action is to
- A. promote ventilation and prevent respiratory acidosis.
- B. increase oxygenation and removal of secretions.
- C. increase pH and facilitate balance of bicarbonate.
- D. prevent respiratory alkalosis by increasing oxygenation.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-primary purpose of this nursing measure is to improve and/or maintain good gas exchange, especially removal of carbon dioxide in order to prevent respiratory acidosis (2) answer choice #1 is better in that it refers to ventilation rather than oxygenation (3) increasing the pH is not desirable (4) respiratory alkalosis is not prevented by this nursing measure
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The nurse is planning discharge for a client who suffered a mild myocardial infarction (MI) and smokes one pack of cigarettes per day.
Which of the following recommendations by the nurse would be BEST?
- A. Participation in a program such as 'Nicotine Avoidance.'
- B. Avoidance of aerobic physical activity.
- C. Instillation of a humidifier in the home heating system.
- D. Strict adherence to a low-calorie, low-sodium, high-lipid diet.
Correct Answer: A
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-smoking is definitely a modifiable risk factor, self-help program can significantly aid in quitting (2) well-planned aerobic physical activity program is a must (3) humidification does not modify the risk factors (4) low-calorie is appropriate, needs a low-fat, not a high-fat, diet
The nurse is caring for a six-year-old boy several hours after the application of a hip spica cast.
- A. What should the nurse do first for a six-year-old complaining of pain in his left foot several hours after hip spica cast application?
- B. Elevate the left leg on two pillows.
- C. Palpate the cast for warmth and wetness.
- D. Administer pain medication as ordered.
- E. Check the blanching sign on both feet.
Correct Answer: D
Rationale: Pain in the foot post-cast application suggests possible circulatory impairment. Checking the blanching sign (capillary refill) assesses circulation, comparing the affected and unaffected sides. Elevation, palpation, or medication may follow but do not address the urgent need to assess circulation.
The nurse is caring for an adult who had a nephrectomy this morning. Because of the location of the surgery, the nurse knows that the client is at increased risk for which of the following?
- A. Thrombophlebitis
- B. Wound infection
- C. Atelectasis
- D. Footdrop
Correct Answer: C
Rationale: Nephrectomy involves flank incision near the diaphragm; postoperative pain limits deep breathing, increasing atelectasis risk. Thrombophlebitis, infection, or footdrop are less specific to the site.
A nurse receives a report on a client 3 days postoperative abdominal surgery that includes four saturated dressing changes in 8 hours. On assessment of this client, dehiscence and evisceration of the wound are noted. After applying a sterile, moistened 4-x-4, what is the nurse's next action?
- A. Place the client in the dorsal recumbent position.
- B. Notify the RN in charge.
- C. Wrap an Ace bandage around the abdomen.
- D. Use a wheelchair to transport the client to the treatment room.
Correct Answer: B
Rationale: After the saline dressing is applied, the RN should be notified—probable repair is necessary. Answer A is wrong because low Fowler's position should be used. Answer C will not help, so it's incorrect. Answer D is inappropriate at this time, so it's incorrect.
The nurse on postpartum is preparing four clients for discharge. It would be MOST important for the nurse to refer which of the following clients for homecare?
- A. A 15-year-old who vaginally delivered a 7-lb male two days ago.
- B. An 18-year-old multipara who delivered a 9-lb female by cesarean section two days ago.
- C. A 20-year-old multipara who delivered 1 day ago and is complaining of cramping.
- D. A 22-year-old who delivered by cesarean section and is complaining of burning on urination.
Correct Answer: D
Rationale: Burning on urination suggests a urinary tract infection, requiring homecare follow-up. Options A, B, and C are routine postpartum findings.