Nokea
The nurse creates a postoperative plan of care for a client undergoing an arthroscopy. The nurse should include which priority action in the plan?
- A. Monitor intake and output.
- B. Assess the tissue at the surgical site.
- C. Monitor the area for numbness or tingling.
- D. Assess the complete blood cell count results.
Correct Answer: C
Rationale: Arthroscopy provides an endoscopic examination of the joint and is used to diagnose and treat acute and chronic disorders of the joint. The priority nursing action is to monitor the affected area for numbness or tingling, which could indicate neurovascular compromise.
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The nurse is assisting a client diagnosed with hepatic encephalopathy to fill out the dietary menu. The nurse advises the client to avoid which entree item?
- A. Tomato soup
- B. Fresh fruit plate
- C. Vegetable lasagna
- D. Ground beef patty
Correct Answer: D
Rationale: Clients with hepatic encephalopathy have impaired ability to convert ammonia to urea and must limit intake of protein and ammonia-containing foods in the diet. The client should avoid foods such as chicken, beef, ham, cheese, milk, peanut butter, and gelatin. The food items in options 1, 2, and 3 are acceptable to eat.
The nurse creates a discharge plan for a client diagnosed with peripheral neuropathy of the lower extremities. Which instructions should the nurse include in the plan? Select all that apply.
- A. Wear support or elastic stockings.
- B. Wear well-fitted shoes and walk barefoot when at home.
- C. Wear dark-colored stockings or socks and change them daily.
- D. Use a heating pad set at low setting on the feet if they feel cold.
- E. Apply lanolin or lubricating lotion to the legs and feet once or twice daily.
- F. Wash the feet and legs with mild soap and water and rinse and dry them well.
Correct Answer: A,E,F
Rationale: Peripheral neuropathy is any functional or organic disorder of the peripheral nervous system. Clinical manifestations can include muscle weakness, stabbing pain, paresthesia or loss of sensation, impaired reflexes, and autonomic manifestations. Home care instructions include wearing support or elastic stockings for dependent edema, applying lanolin or lubricating lotion to the legs and feet once or twice daily, washing the feet and legs with mild soap and water and rinsing and drying them well, inspecting the legs and feet daily and reporting any skin changes or open areas to the primary health care provider.
The nurse monitors the client taking amitriptyline for which common side effect?
- A. Diarrhea
- B. Drowsiness
- C. Hypertension
- D. Increased salivation
Correct Answer: B
Rationale: Common side effects of amitriptyline (a tricyclic antidepressant) include the central nervous system effects of drowsiness, fatigue, lethargy, and sedation. Other common side effects include dry mouth or eyes, blurred vision, hypotension, and constipation. The nurse monitors the client for these side effects.
The primary health care provider prescribes 250 mg of amikacin sulfate every 12 hours. How many milliliters (mL) should the nurse prepare to administer one dose? Refer to the figure.
Correct Answer: 5
Rationale: Use the medication calculation formula. Formula: (Desired × mL) / Available = mL per dose. (250 mg × 2 mL) / 100 mg = 5 mL per dose.
The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding?
- A. Equal bilateral chest expansion
- B. Respiratory rate of 22 breaths per minute
- C. Diminished breath sounds on the affected side
- D. Few scattered wheezes, unchanged from baseline
Correct Answer: C
Rationale: After thoracentesis, the nurse assesses vital signs and breath sounds. The nurse especially notes increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis, which could indicate pneumothorax. Any of these manifestations should be reported to the primary health care provider. Options 1 and 2 are normal findings. Option 4 indicates a finding that is unchanged from the baseline.