Nokea
The nurse cares for a client scheduled for spinal surgery in one hour. The nurse anticipates that the primary healthcare provider (PHCP) will prescribe
- A. gentamicin
- B. enoxaparin
- C. hydromorphone
- D. cyclobenzaprine
Correct Answer: B
Rationale: Enoxaparin, a low-molecular-weight heparin, is commonly prescribed preoperatively for spinal surgery to prevent venous thromboembolism due to prolonged immobility. Gentamicin is an antibiotic, hydromorphone is for pain, and cyclobenzaprine is a muscle relaxant, none of which are typically prioritized preoperatively for this purpose.
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The nurse is caring for a client who reports abdominal pain. When performing an abdominal assessment, the nurse should
- A. Auscultate for bowel sounds after inspecting the abdomen.
- B. Palpate the area where the client identifies pain prior to palpating other areas.
- C. Palpate to detect fluid, air, and fluid-filled or solid masses.
- D. Percuss for masses, tenderness, organ enlargement, and ascites.
Correct Answer: A
Rationale: Abdominal assessment follows the order: inspect, auscultate, percuss, palpate. Auscultation after inspection prevents altering bowel sounds. Palpating painful areas first or focusing only on palpation/percussion is incorrect.
The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?
- A. Blood pressure
- B. End-tidal carbon dioxide [ETCO2] level
- C. Respiratory rate
- D. Blood glucose
- E. Oxygen saturation
Correct Answer: A,B,C,E
Rationale: During moderate sedation, monitoring blood pressure, end-tidal CO2, respiratory rate, and oxygen saturation is essential to assess cardiovascular and respiratory status, ensuring patient safety. Blood glucose is not routinely monitored unless indicated by the patient’s condition.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
The nurse is performing a health assessment on a client. While performing percussion, which percussion sound would require follow-up?
- A. Dull tone over the spleen
- B. Hyperresonance over an adult's lung tissue
- C. Flat tone over bone
- D. Hyperresonance over a child's lung tissue
Correct Answer: B
Rationale: Hyperresonance in adult lungs suggests pneumothorax or emphysema, requiring follow-up. Dullness over spleen, flatness over bone, and hyperresonance in children are normal.
The nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescription should the nurse clarify with the primary healthcare physician (PHCP)?
- A. Lispro insulin 5 units SubQ TID
- B. Glargine insulin 15 units SubQ QHS
- C. Vitamin B12 100 mcg IM Daily
- D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days
Correct Answer: A
Rationale: Lispro insulin is a rapid-acting insulin typically administered around mealtimes to manage postprandial glucose levels. Since the client is NPO, they are not eating, so administering lispro insulin could lead to hypoglycemia due to the absence of carbohydrate intake. The nurse should clarify this prescription with the PHCP to ensure safe management of the client’s blood glucose levels during the NPO period. Glargine insulin, a long-acting insulin, is appropriate for basal glucose control and does not require clarification. Vitamin B12 and clonidine are unrelated to food intake and safe for NPO status.