Nokea
The nurse is assessing a client 2 hours postoperatively after a femoral popliteal bypass. The upper leg dressing becomes saturated with blood. The nurse's first action should be to
- A. Wrap the leg with elastic bandages
- B. Apply pressure at the bleeding site
- C. Reinforce the dressing and elevate the leg
- D. Remove the dressings and re-dress the incision
Correct Answer: B
Rationale: In this scenario where the upper leg dressing becomes saturated with blood post-femoral popliteal bypass, the nurse's first action should be to apply pressure at the bleeding site. Applying pressure is essential to control hemorrhage and prevent further blood loss.
Choice A is incorrect as wrapping the leg with elastic bandages would not address the immediate issue of controlling the bleeding.
Choice C is incorrect because reinforcing the dressing and elevating the leg should come after controlling the bleeding.
Choice D is incorrect as removing the dressings and re-dressing the incision should only be done after the bleeding is under control to prevent excessive blood loss.
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A client has viral pneumonia affecting 2/3 of the right lung. What would be the best position to teach the client to lie in every other hour during the first 12 hours after admission?
- A. Side-lying on the left with the head elevated 10 degrees
- B. Side-lying on the left with the head elevated 35 degrees
- C. Side-lying on the right with the head elevated 10 degrees
- D. Side-lying on the right with the head elevated 35 degrees
Correct Answer: A
Rationale: The correct position for a client with viral pneumonia affecting 2/3 of the right lung is side-lying on the left with the head elevated 10 degrees. This position helps maximize lung expansion and oxygenation in cases of pneumonia affecting the right lung. Choice B is incorrect as excessive elevation can put pressure on the lung, and choices C and D are incorrect as side-lying on the right would not be beneficial for a client with pneumonia in the right lung.
A nurse is providing anticipatory guidance to the parents of a newborn about feeding skills. Which of the following is not an infant's feeding skill?
- A. Pushes solid objects from mouth
- B. Eats foods that are higher in fat
- C. Begins experimenting with a spoon
- D. Eats pieces of soft, cooked food
Correct Answer: B
Rationale: The correct answer is B. When discussing infant feeding skills, it is important to note that eating foods higher in fat is not considered a specific feeding skill for newborns. The typical progression of feeding skills includes pushing solid objects from the mouth, eating pieces of soft, cooked food, drinking from a cup held by another person, and experimenting with a spoon. Choices A, C, and D correspond to the expected developmental sequence of feeding skills for infants, making them incorrect answers in this context.
A 60-year-old male client had a hernia repair in an outpatient surgery clinic. He is awake and alert, but has not been able to void since he returned from surgery 6 hours ago. He received 1000 mL of IV fluid. Which action would be most likely to help him void?
- A. Have him drink several glasses of water
- B. Crede the bladder from the bottom to the top
- C. Assist him to stand by the side of the bed to void
- D. Wait 2 hours and have him try to void again
Correct Answer: C
Rationale: Assisting the client to stand by the side of the bed to void is the most appropriate action. This position can help stimulate voiding due to gravity and normal positioning. Having the client drink water (Choice A) may help, but assisting him to stand is more effective. Crede maneuver (Choice B) is not recommended as it can increase the risk of bladder trauma. Waiting for 2 hours (Choice D) without taking any action is not proactive in addressing the client's inability to void.
The nurse is caring for a client with a new diagnosis of diabetes mellitus. Which of these statements made by the client indicates a need for further teaching?
- A. I will monitor my blood glucose levels regularly and keep a record to show my healthcare provider.
- B. I will follow my meal plan and exercise regularly to help manage my blood sugar levels.
- C. I will stop taking my medications if my blood sugar levels are normal.
- D. I will continue to take my medications even if I feel better.
Correct Answer: C
Rationale: Choice C indicates a need for further teaching because stopping medications when blood sugar levels are normal can lead to uncontrolled blood sugar levels if the individual does not understand the importance of medication adherence in managing diabetes. Choices A, B, and D are correct statements that demonstrate good understanding of managing diabetes, such as monitoring blood glucose levels, following a meal plan, exercising regularly, and adhering to medication even when feeling better.
A client with a history of asthma is admitted to the emergency department with difficulty breathing. Which of these assessments is the highest priority for the nurse to perform?
- A. Auscultation of breath sounds
- B. Measurement of peak expiratory flow
- C. Observation of the client's use of accessory muscles
- D. Assessment of the client's skin color
Correct Answer: A
Rationale: Auscultation of breath sounds is the highest priority assessment in a client with a history of asthma experiencing difficulty breathing. It helps the nurse evaluate the severity of the asthma exacerbation by listening for wheezing, crackles, or decreased breath sounds. This assessment guides treatment decisions, such as administering bronchodilators or oxygen therapy. Measurement of peak expiratory flow, although important in assessing asthma severity, may not be feasible in an emergency situation where immediate intervention is needed. Observation of accessory muscle use and assessment of skin color are also important assessments in asthma exacerbation, but auscultation of breath sounds takes precedence in determining the need for urgent interventions.