Nokea
The healthcare provider is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?
- A. Taking birth control pills for the past 2 years
- B. Taking anticoagulants for the past year
- C. Recently completing antibiotic therapy
- D. Having taken laxatives PRN for the last 6 months
Correct Answer: B
Rationale: Anticoagulants increase the risk of bleeding during surgery, which can lead to complications such as excessive bleeding and difficulty in achieving hemostasis. This poses a significant threat during a surgical procedure where controlling bleeding is crucial for a successful outcome. The other options (A, C, D) are not as critical as anticoagulants in terms of posing a threat for complications during surgery. Birth control pills, recently completing antibiotic therapy, and using laxatives do not directly impact bleeding risks during surgery compared to anticoagulants.
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When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?
- A. Determine if the expected outcomes were realistic
- B. Obtain current client data to compare with expected outcomes
- C. Modify the nursing interventions to achieve the client's goals
- D. Review related professional standards of care
Correct Answer: A
Rationale: After reviewing the expected outcomes identified in the plan of care, the nurse's next step should be to determine if these outcomes were realistic. This assessment helps in understanding if the goals set were achievable and appropriate for the client's condition before proceeding to compare them with current client data or modifying nursing interventions. By verifying the realism of the expected outcomes, the nurse ensures a solid foundation for further evaluation and adjustment of the care plan. Option B is incorrect because obtaining current client data comes after assessing the realism of the expected outcomes. Option C is incorrect because modifying nursing interventions should be based on the assessment of the expected outcomes' realism. Option D is incorrect as reviewing professional standards of care is important but not the immediate next step after assessing the expected outcomes' realism.
Mr. Landon is scheduled to undergo a tracheostomy. Which nursing action is essential during tracheal suctioning?
- A. Using a water-soluble lubricant.
- B. Administering 100% oxygen before and after suctioning.
- C. Ensuring that the suction catheter is open during insertion.
- D. Assisting the client to assume a semi-Fowler's position during suctioning.
Correct Answer: B
Rationale: Administering 100% oxygen before and after suctioning is crucial to prevent hypoxia, which can occur during tracheal suctioning. Hypoxia can lead to serious complications, making the provision of oxygen essential in maintaining adequate oxygenation levels for the patient undergoing tracheal suctioning. Choice A is incorrect because using a water-soluble lubricant is not directly related to the essential nursing action during tracheal suctioning. Choice C is incorrect as ensuring that the suction catheter is open during insertion is a basic requirement and not the essential action for oxygenation. Choice D is incorrect because assisting the client to assume a semi-Fowler's position is beneficial for comfort and airway alignment but is not as crucial as administering oxygen to prevent hypoxia.
The father of an 11-year-old client reports to the nurse that the client has been 'wetting the bed' since the passing of his mother and is concerned. Which action is most important for the nurse to take?
- A. Reassure the father that it is normal for a child to wet the bed after a traumatic event
- B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed
- C. Inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma
- D. Refer the father and the client to a psychologist
Correct Answer: C
Rationale: Bedwetting after trauma, such as losing a parent, is common in children. The nurse should inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma. Reassurance and understanding are essential in addressing the child's emotional needs during this difficult time. Choice A is incorrect as it focuses on puberty rather than trauma as the underlying cause. Choice B is incorrect as it provides inaccurate information about nocturnal emissions and developmental delay. Choice D is premature as the first step should be to provide education and support before considering a referral to a psychologist.
When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?
- A. Position the client supine for a few minutes
- B. Assist the client to stand at the bedside
- C. Apply the blood pressure cuff securely
- D. Record the client's pulse rate and rhythm
Correct Answer: A
Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.
When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first?
- A. Divert the client's attention
- B. Call for additional help from staff
- C. Document the planned action
- D. Re-assess the client's situation
Correct Answer: D
Rationale: Before providing care to an anxious client, it is crucial for the nurse to first re-assess the client's situation. By re-assessing, the nurse can understand the underlying cause of the client's anxiety, which will help in tailoring appropriate care interventions. Re-assessment ensures that care provided is individualized and addresses the client's specific needs, promoting effective and client-centered care delivery. Diverting the client's attention (Choice A) may not address the root cause of the anxiety. Calling for additional help (Choice B) may be necessary in some situations but should not be the first action. Documenting the planned action (Choice C) should come after re-assessing the client's situation to ensure accurate documentation based on the current assessment.