Nokea
On admission to same-day surgery, the nurse reviews the chart to verify the client's identification documentation. Which of the following is most important?
- A. Admitting record.
- B. Addressograph labels.
- C. Identification bracelet.
- D. Location of family.
Correct Answer: C
Rationale: The identification bracelet is the most reliable method to verify client identity, ensuring safety and preventing errors in same-day surgery.
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Which outcome is realistic for a client with a chronic neurological condition?
- A. Complete symptom reversal.
- B. Maintain functional ability.
- C. Eliminate all medications.
- D. Prevent all complications.
Correct Answer: B
Rationale: Maintaining functional ability is a realistic goal for managing chronic neurological conditions.
A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
One goal of care for a client with PVD is to decrease anxiety, so as to decrease or prevent vasoconstriction of the:
- A. Arteries
- B. Capillaries
- C. Lymphatics
- D. Veins
Correct Answer: A
Rationale: Anxiety can trigger sympathetic nervous system activation, causing arterial vasoconstriction, which worsens ischemia in PVD. Reducing anxiety helps maintain arterial dilation and blood flow. Capillaries, lymphatics, and veins are less affected by this mechanism.
A client has returned from surgery during which her jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed nursing personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the UAP?
- A. Keep the client in a side-lying position with the head slightly elevated.
- B. Do not reposition the client without the assistance of a registered nurse.
- C. The client can assume any position that is comfortable.
- D. Keep the client's head elevated on two pillows at all times.
Correct Answer: A
Rationale: A side-lying position with the head slightly elevated helps prevent aspiration and maintains airway patency in a client with wired jaws. The other options are either overly restrictive, unsafe, or not optimal for airway management.
Which of the following is most likely to cause the client to experience postoperative nausea and vomiting?
- A. Total hip replacement.
- B. Mitral valve repair.
- C. Abdominal hysterectomy.
- D. Mastectomy of the left breast.
Correct Answer: C
Rationale: Abdominal hysterectomy involves manipulation of the gastrointestinal tract, increasing the risk of postoperative nausea and vomiting due to vagal stimulation and slowed gastric motility.