Nokea
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration
- B. The client will require frequent dressing changes
- C. The straps provide support for drains that are inserted into the incision
- D. No sutures or clips are used to secure the incision
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.
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A 60-year-old diabetic is taking glyburide (Diabeta) 1.25 mg daily to treat Type II diabetes mellitus. Which statement indicates the need for further teaching?
- A. I will keep candy with me just in case my blood sugar drops.
- B. I need to stay out of the sun as much as possible.
- C. I often skip dinner because I don't feel hungry.
- D. I always wear my medical identification.
Correct Answer: C
Rationale: Skipping meals while on glyburide increases hypoglycemia risk, indicating a need for further teaching.
The nurse is caring for a 72-year-old female who must remain on bed rest after a hip fracture. The client has become confused and disoriented over the past 2 days. Which of the following is the best nursing intervention?
- A. placing familiar objects such as family photos, a clock, and a personal calendar on the wall
- B. asking the physician to order restraints so the client does not try and get up
- C. asking the client's daughter to stay overnight so the client is comforted by a familiar face
- D. moving the client to a better staffed floor, so she can be watched more carefully
Correct Answer: A
Rationale: Familiar objects like photos, clocks, and calendars help reorient a confused client, reducing disorientation safely. Restraints are a last resort, and the other options are less effective.
A 32-year-old mother of three is brought to the clinic. Her pulse is 52, there is a weight gain of 30 pounds in 4 months, and the client is wearing two sweaters. The client is diagnosed with hypothyroidism. Which of the following nursing diagnoses is of highest priority?
- A. Impaired physical mobility related to decreased endurance
- B. Hypothermia r/t decreased metabolic rate
- C. Disturbed thought processes r/t interstitial edema
- D. Decreased cardiac output r/t bradycardia
Correct Answer: D
Rationale: Bradycardia in hypothyroidism can lead to decreased cardiac output, which is life-threatening and thus the highest priority diagnosis.
A child with Tetralogy of Fallot is scheduled for a modified Blalock Taussig procedure. The nurse understands that the surgery will:
- A. Reverse the direction of the blood flow
- B. Allow better blood supply to the lungs
- C. Relieve pressure on the ventricles
- D. Prevent the need for further correction
Correct Answer: B
Rationale: The modified Blalock-Taussig procedure creates a shunt to improve pulmonary blood flow in Tetralogy of Fallot, enhancing lung oxygenation.
A client comes into the emergency room after a chemical splashed into her eye at work. The priority nursing intervention is to
- A. cover the eye with a sterile cloth.
- B. determine what chemical splashed into the eye.
- C. irrigate the eye with normal saline solution.
- D. test vision in the affected eye.
Correct Answer: C
Rationale: Immediate irrigation with saline removes the chemical, preventing further eye damage. Other actions follow after irrigation.