Nokea
The nurse in the intensive care unit is giving a report to the nurse in the post-surgical unit about a client who had a gastrectomy. The most effective way to assure essential information about the client is reported is to:
- A. Give the report face-to-face with both nurses in a quiet room.
- B. Audiotape the report for future reference and documentation.
- C. Use a printed checklist with information individualized for the client.
- D. Document essential transfer information in the client's electronic health record.
Correct Answer: C
Rationale: A printed checklist individualized for the client ensures all essential information is communicated consistently and reduces the risk of omissions during the report.
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After knee arthroplasty, the client has a sequential compression device (SCD). The nurse should do which of the following?
- A. Elevate the sequential compression device (SCD) on two pillows.
- B. Change the settings on the SCD to make the client more comfortable.
- C. Use the SCD to remove dressings and bathe the leg.
- D. Discontinue the SCD when the client is ambulatory.
Correct Answer: D
Rationale: The SCD is discontinued when the client is ambulatory, as mobility reduces the risk of thrombosis.
The nurse is planning care for a client with a history of peripheral vascular disease who has symptoms of claudication. Nursing care should be directed to avoiding which of the following situations?
- A. Oxygen demand by the muscle exceeds the supply
- B. Oxygen demand and supply of the working muscle are in balance
- C. Oxygen supply exceeds the demand of the working muscle
- D. Oxygen is absent
Correct Answer: A
Rationale: Claudication in PVD results from insufficient blood flow to muscles during activity, causing oxygen demand to exceed supply, leading to pain. Nursing care should aim to improve blood flow (e.g., through exercise programs or medications) and avoid situations where muscle oxygen demand outstrips supply. Balanced or excess supply is desirable, and complete oxygen absence is not typical in claudication.
A client is admitted from the emergency department after falling down a flight of stairs at home. Her vital signs are stable and her history states that she had a gastric stapling 2 years ago and takes neomycin for acne. The client jokes about how she is clumsy lately and trips over things. The nurse should ask the client which of the following questions? Select all that apply.
- A. Are you experiencing numbness in your extremities?'
- B. How much vitamin B12 are you getting?'
- C. Are you feeling depressed?'
- D. Do you feel safe at home?'
- E. Are you getting sufficient iron in your diet?'
Correct Answer: A,B,D
Rationale: Gastric stapling can impair vitamin B12 absorption, and neomycin may further reduce B12 levels by altering gut flora. The client's clumsiness and falls suggest possible B12 deficiency neuropathy, warranting questions about numbness and B12 intake. Asking about safety at home is crucial to assess for environmental or abuse-related causes of falls. Depression and iron intake are less directly related to the symptoms described.
The nurse is documenting care of a client who is restrained in bed with bilateral wrist restraints. Following assessment of the restraints, the nurse's documentation should include which of the following? Select all that apply.
- A. Nutrition and hydration needs.
- B. Circulation and skin integrity.
- C. Range of motion and positioning.
- D. Behavioral responses and mental status.
Correct Answer: A,B,C,D
Rationale: Documentation must include nutrition/hydration, circulation/skin integrity, range of motion/positioning, and behavioral/mental status to ensure safety and compliance.
The nurse has attended a continuing education conference regarding medication administration and meal times. Which statement, if made by the nurse, would indicate correct understanding?
- A. Proton pump inhibitors (PPls) should be given as the client eats their breakfast.
- B. Glucocorticoids should be given on an empty stomach to prevent gastrointestinal irritation.
- C. Rapid-acting insulins should be administered approximately 5-10 minutes before meals
- D. Levodopa-Carbidopa should be administered with a high-protein snack to enhance its absorption.
Correct Answer: C
Rationale: Rapid-acting insulins are administered 5-10 minutes before meals to match glucose spikes.