Nokea
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate 125 beats/minute, respiratory rate 36 breaths/minute, and blood pressure 166/88 mm Hg. Which nursing intervention(s) should the nurse implement? (Select all that apply.)
- A. Present a calm, supportive demeanor.
- B. Reorient to day and time frequently.
- C. Administer an as needed (PRN) dose of lorazepam.
- D. Turn the television on for distraction.
- E. Apply soft wrist restraints bilaterally.
Correct Answer: A,B,C
Rationale: Presenting a calm, supportive demeanor, reorienting to day and time frequently, and administering a PRN dose of lorazepam are appropriate interventions to reduce anxiety, agitation, and hallucinations while promoting trust and orientation.
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A client who had a biliopancreatic diversion procedure (BPD) 3 months ago is admitted with severe dehydration. Which assessment finding warrants immediate intervention by the nurse?
- A. Gastroccult positive emesis.
- B. Strong foul smelling flatus.
- C. Complaint of poor night vision.
- D. Loose bowel movements.
Correct Answer: A
Rationale: Gastroccult positive emesis indicates the presence of blood in the vomit, which is a sign of a serious complication such as anastomotic leak, ulcer, or bleeding. The nurse should notify the physician and monitor the client's vital signs and hemoglobin level.
The nurse is providing dietary instructions for a client who is being discharged after passing a calcium oxalate renal stone. Which food should the nurse instruct the client to avoid?
- A. Sweet potatoes.
- B. Spinach salad.
- C. Bananas.
- D. Fish.
Correct Answer: B
Rationale: Spinach salad is high in oxalate, which can combine with calcium in the urine to form stones, increasing the risk of recurrence.
A client with a closed head injury demonstrates signs of syndrome of inappropriate antidiuretic hormone (SIADH). Which additional finding should the nurse expect to obtain?
- A. Weight gain of 2 pounds (0.91 kg) in one day.
- B. Fremitus over the chest wall.
- C. Serum sodium of 150 mEq/L (150 mmol/L).
- D. Urine specific gravity of 1.004.
Correct Answer: A
Rationale: Weight gain of 2 pounds (0.91 kg) in one day is a sign of fluid retention, which occurs in SIADH due to excessive secretion of antidiuretic hormone (ADH). ADH causes the kidneys to reabsorb water and reduce urine output, leading to hyponatremia and hypervolemia.
The nurse is preparing an older client for a magnetic resonance imaging (MRI) with contrast. Which laboratory value should the nurse report to the healthcare provider before the scan is performed?
- A. Fasting blood sugar of 200 mg/dL (11.1 mmol/L).
- B. Glycosylated hemoglobin A1c of 8%.
- C. Blood urea nitrogen of 22 mg/dL (7.9 mmol/L).
- D. Serum creatinine of 1.9 mg/dL (169 umol/L).
Correct Answer: D
Rationale: Serum creatinine of 1.9 mg/dL (169 umol/L) indicates moderate renal insufficiency, which can increase the risk of contrast-induced nephropathy, a sudden deterioration of kidney function after exposure to contrast media used for imaging studies such as MRI. This should be reported to the healthcare provider to assess the risk and benefit of the procedure and to take preventive measures such as hydration or alternative imaging modalities.
Flow sheets
1915
Arrival at emergency department
1920
Vital Signs:
- Temperature: 98.2° F (36.8° C)
- Heart rate: 92 beats/minute
- Respirations: 24 breaths/minute
- Blood pressure: 210/98 mmHg
- Oxygen saturation: 95% on room air
Imaging studies
1935
Head CT scan results:
- No evidence of intracranial hemorrhage
- No evidence of acute disease
Orders
- Obtain CT scan of the head.
- Insert a large bore peripheral IV.
- Start normal saline infusion at 50 mL/hour.
The nurse administered tPA and conducted neurologic assessments every 15 minutes during the infusion. The tPA infusion finished and the nurse performed neurologic assessments every 30 minutes for the 6 hours following the administration. The client was noted to be stable with unchanged neurologic assessments. The nurse begins to plan care for the client's recovery and identifies interdisciplinary team members who can assist with the client's recovery.
A 70-year-old female presents to the emergency department through triage with a noticeable facial droop and garbled speech. After having a few drinks at a local seafood restaurant, the client's husband noticed his wife's speech became difficult to understand. Select the interdisciplinary team members who should assist the client in recovery.
- A. Occupational Therapist
- B. Speech Therapist
- C. Case manager
- D. Physical therapist
- E. Chief Nursing Officer
- F. Pharmacy Technician
Correct Answer: A,B,C,D
Rationale: Occupational, speech, and physical therapists address stroke-related impairments in daily activities, communication, and mobility, while a case manager coordinates care and discharge planning.