Nokea
The nurse in the preoperative holding area keeps a client with gastric bleeding in a dimly lit environment with one family member present. What is the primary rationale for these nursing interventions?
- A. To stabilize fluid and electrolyte balance.
- B. To minimize oxygen consumption.
- C. To increase client and family comfort.
- D. To prevent infection.
Correct Answer: B
Rationale: A dimly lit environment and limited visitors reduce stimulation, minimizing oxygen consumption in a client with gastric bleeding, who may be hypoxic due to anemia. Comfort is secondary, and these measures do not directly stabilize fluids or prevent infection.
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What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.
A nurse is treating a client who came to the emergency department after getting bit by a snake on their arm. After confirming the resuscitation equipment is at the bedside, which of the following actions by the nurse would be a priority?
- A. Contact Poison Control for guidance on an antivenom.
- B. Ensure the client's peripheral intravenous (IV) lines are patent.
- C. Apply a tourniquet above the snake bitten area on the arm.
- D. Assess for rash, fever, chills, nausea, vomiting, and joint pain.
Correct Answer: B
Rationale: Ensuring patent IV lines is the priority to enable rapid antivenom or fluid administration, critical for snakebite management. Contacting Poison Control (A) is secondary, tourniquets (C) are harmful, and symptom assessment (D) is important but not the immediate priority.
After surgery for head and neck cancer, a client has a permanent tracheostomy. The nurse should teach the client and family about the importance of:
- A. Providing tracheostomy site care.
- B. Addressing the psychosocial issues related to tracheostomy.
- C. Observing for early signs and symptoms of skin breakdown around the tracheostomy site.
- D. Using humidifiers to prevent thick, tenacious secretions.
Correct Answer: A,C,D
Rationale: Tracheostomy site care (A), monitoring for skin breakdown (C), and using humidifiers (D) are critical to prevent infection, maintain skin integrity, and keep secretions manageable.
The emergency department (ED) nurse cares for a client receiving prescribed warfarin and reports dizziness, black tarry stools, and bloody gums. The international normalized ratio (INR) returns at 5 (0.9-1.2 seconds). The nurse anticipates the primary healthcare provider (PHCP) will prescribe which blood product?
- A. Packed red blood cells (PRBCs)
- B. Platelets
- C. Granulocytes
- D. Fresh frozen plasma (FFP)
Correct Answer: D
Rationale: An INR of 5 indicates significant anticoagulation from warfarin, increasing bleeding risk (evidenced by tarry stools and bloody gums). FFP provides clotting factors to reverse warfarin’s effects. PRBCs address anemia, platelets address thrombocytopenia, and granulocytes treat infections, none of which are primary here.
The nurse should teach the client with an ileal conduit to prevent urine leakage when changing the appliance by using which of the following procedures?
- A. Insert a gauze wick into the stoma.
- B. Close the opening temporarily with a cellophane seal.
- C. Suction the stoma before changing the appliance.
- D. Avoid oral fluids for several hours before changing the appliance.
Correct Answer: A
Rationale: Inserting a gauze wick into the stoma temporarily absorbs urine, preventing leakage during appliance changes, ensuring a dry field for secure adhesion.