Nokea
The family cannot go with the surgical client past the doors that separate the public from the restricted area of the operating room suite. These traffic control measures are designed to:
- A. Protect the privacy of clients.
- B. Prevent electrical sparks that could ignite the anesthetic gases.
- C. Separate the family from the surgical team to prevent distraction of the client.
- D. Provide for an aseptic environment to prevent infection.
Correct Answer: D
Rationale: Restricting access to the operating room maintains an aseptic environment, reducing the risk of surgical site infections by limiting contamination.
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The nurse should expect single-donor platelets to be ordered for which of the following clients?
- A. A client who is receiving multiple platelet transfusions.
- B. A client who is deficient in coagulation factors.
- C. A client whose platelet count is greater than 50,000/mm³.
- D. A client who is refractory to random-donor platelets.
Correct Answer: D
Rationale: Single-donor platelets are used for clients refractory to random-donor platelets to reduce the risk of alloimmunization and improve transfusion efficacy.
After a myocardial infarction, the hospitalized client is taught to move the legs while resting in bed. This type of exercise is recommended primarily to help:
- A. Prepare the client for ambulation.
- B. Promote urinary and intestinal elimination.
- C. Prevent thrombophlebitis and blood clot formation.
- D. Decrease the likelihood of pressure ulcer formation.
Correct Answer: C
Rationale: Leg exercises prevent venous stasis, reducing the risk of thrombophlebitis and deep vein thrombosis, common complications post-MI due to immobility.
A nurse is making follow-up phone calls to clients being treated for cancer. Place the options below in the order of priority that the nurse should return the calls.
- A. The client receiving chemotherapy who complains of a loss of appetite.
- B. The client who underwent a mastectomy 2 weeks ago who called for information on the Reach for Recovery program.
- C. The client receiving spinal radiation for bone cancer metastases who complains of urinary incontinence.
- D. The client with colon cancer who has questions about a high-fiber diet.
Correct Answer: C,A,B,D
Rationale: Urinary incontinence (C) may indicate a serious complication like spinal cord compression, requiring immediate attention. Loss of appetite (A) during chemotherapy can lead to malnutrition, followed by the mastectomy client's support needs (B), and then dietary questions (D).
The client with chronic pancreatitis should be monitored closely for the development of which of the following disorders?
- A. Cholelithiasis.
- B. Hepatitis.
- C. Irritable bowel syndrome.
- D. Diabetes mellitus.
Correct Answer: D
Rationale: Chronic pancreatitis damages pancreatic tissue, impairing insulin production and increasing the risk of diabetes mellitus (D). Cholelithiasis (A), hepatitis (B), and irritable bowel syndrome (C) are less directly related.
A client with diverticulitis has developed peritonitis following diverticular rupture. The nurse should assess the client to determine which of the following? Select all that apply.
- A. Percuss the abdomen to note resonance and tympany.
- B. Percuss the liver to note lack of dullness.
- C. Monitor the vital signs for fever, tachypnea, and bradycardia.
- D. Assess presence of polyphagia and polydipsia.
- E. Auscultate bowel sounds to note frequency.
Correct Answer: B,C
Rationale: In peritonitis, the nurse should percuss the liver for lack of dullness (B), indicating free air, and monitor vital signs for fever, tachypnea, and tachycardia (not bradycardia) (C). Resonance and tympany, polyphagia, polydipsia, and bowel sound frequency are less specific for peritonitis. CN: Physiological adaptation; CL: Analyze