Nokea
The healthcare provider is assessing a client who has just undergone abdominal surgery. Which finding should be reported to the healthcare provider immediately?
- A. Absence of bowel sounds
- B. Mild abdominal distention
- C. Drainage of serosanguineous fluid from the incision
- D. Sudden onset of severe abdominal pain
Correct Answer: D
Rationale: Sudden onset of severe abdominal pain may indicate complications such as peritonitis, bowel perforation, or internal bleeding. These conditions are serious and require immediate medical attention to prevent further complications or deterioration. Absence of bowel sounds, mild abdominal distention, and drainage of serosanguineous fluid are common findings after abdominal surgery and may not necessarily indicate an emergency situation requiring immediate reporting to the healthcare provider. Severe abdominal pain post-surgery should always be reported promptly as it could signify a life-threatening situation that needs urgent evaluation and intervention.
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How should the nurse respond to an older male client who states that his religion does not permit him to bathe daily?
- A. Review the importance of hygienic measures for improved health
- B. State that the healthcare provider has prescribed a bath today
- C. Offer the client several choices of times to bathe during the day
- D. Request that the client clarify his religious beliefs about bathing
Correct Answer: C
Rationale: The correct response is to offer the client several choices of times to bathe during the day. This approach respects the client's religious beliefs while ensuring that hygienic practices are still maintained. By providing options, the nurse can work together with the client to find a solution that aligns with both his beliefs and his health needs. Choice A is incorrect because solely reviewing the importance of hygiene may not address the client's specific religious concerns. Choice B is inappropriate as it disregards the client's beliefs and autonomy. Choice D is not the best approach as it may come off as confrontational or dismissive of the client's beliefs, rather than working collaboratively to find a suitable solution.
The healthcare provider is assessing a client who has just undergone a thyroidectomy. Which assessment finding is most concerning?
- A. Hoarseness of the voice
- B. Slight swelling at the incision site
- C. Tingling around the mouth
- D. Mild fever
Correct Answer: C
Rationale: Tingling around the mouth is the most concerning finding as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common due to surgical manipulation, slight swelling at the incision site is expected postoperatively, and mild fever can be a normal inflammatory response. Hypocalcemia after thyroidectomy can lead to serious complications and should be addressed promptly to prevent further issues.
While caring for a client's postoperative dressing, the nurse observes purulent wound drainage. Previously, the wound was inflamed and tender but without drainage. Which is the most important action for the nurse to take?
- A. Determine if the drainage has an unpleasant odor.
- B. Monitor the client's white blood cell count (WBC).
- C. Request a culture and sensitivity of the wound.
- D. Cleanse the wound with a sterile saline solution.
Correct Answer: C
Rationale: Requesting a culture and sensitivity of the wound is the most crucial action in this scenario. This will help identify the specific organism causing the infection and determine its sensitivity to antibiotics, guiding appropriate antibiotic therapy. Option A is less critical as odor alone may not provide enough information about the type of infection. Monitoring the client's white blood cell count (WBC) in option B is important but not as immediate as obtaining a wound culture. Cleansing the wound with a sterile saline solution in option D is necessary but should follow after obtaining the culture results to ensure proper treatment.
The nurse is caring for a client with increased intracranial pressure (ICP). Which position should the nurse avoid?
- A. Keeping the head of the bed elevated at 30 degrees
- B. Positioning the client in the prone position
- C. Placing the client in a lateral recumbent position
- D. Elevating the client's legs
Correct Answer: B
Rationale: The correct answer is B: Positioning the client in the prone position. Placing the client in the prone position should be avoided in a client with increased intracranial pressure (ICP) as it can further raise ICP. The prone position can hinder venous return and increase pressure within the cranial vault, potentially worsening the client's condition. Keeping the head of the bed elevated at 30 degrees helps promote venous drainage and reduce ICP. Placing the client in a lateral recumbent position can also assist in reducing ICP by optimizing cerebral perfusion. Elevating the client's legs can help improve venous return and maintain adequate cerebral blood flow, making it a suitable positioning intervention for managing increased ICP.
After placing a client at 26-weeks gestation in the lithotomy position, the client complains of dizziness and becomes pale and diaphoretic. What action should the nurse implement?
- A. Instruct the client to take deep breaths.
- B. Place a wedge under the client's hip.
- C. Place the client in the Trendelenburg position.
- D. Remove the client's legs from the stirrups.
Correct Answer: B
Rationale: Placing a wedge under the client's hip is the correct action in this scenario. This helps relieve the pressure on the vena cava, which can become compressed in the lithotomy position during pregnancy, improving circulation and reducing symptoms like dizziness and pallor. Instructing the client to take deep breaths (Choice A) may not address the underlying cause of the symptoms. Placing the client in the Trendelenburg position (Choice C) would worsen the situation by further compressing the vena cava. Removing the client's legs from the stirrups (Choice D) may provide temporary relief but does not address the root cause of the issue.