Nokea
The nurse is assessing a client following a coronary artery bypass graft (CABG). The nurse should give priority to reporting:
- A. Chest drainage of 150 mL in the past hour
- B. Confusion and restlessness
- C. Pallor and coolness of skin
- D. Urinary output of 40 mL per hour
Correct Answer: A
Rationale: Chest drainage of 150 mL/hour post-CABG suggests significant bleeding, requiring immediate reporting to prevent hypovolemia. Confusion, pallor, and low urine output are less urgent.
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A 49-year-old obese woman has been admitted to the general surgery unit with choledocholithiasis. As the nurse is admitting her to the unit, she states, 'The doctor said I have stones that need to be removed; where are they?' The nurse knows that the best explanation for this is to tell her that:
- A. There are stones present in her gallbladder
- B. There are stones present in her kidneys
- C. There are stones present in her common bile duct
- D. There are no stones, but her gallbladder is irritated and caused her nausea, vomiting, and pain
Correct Answer: C
Rationale: Cholelithiasis is the correct term used to describe the presence of stones in the gallbladder. Nephrolithiasis, or renal calculi, is the correct term used to describe the presence of stones in the kidney. Choledocholithiasis is the correct term used to describe the presence of stones in the common bile duct. Cholecystitis is the correct term used to describe inflammation of the gallbladder and can be associated with cystic duct obstructions from impacted stones.
The nurse is caring for a client with a T4 spinal cord injury. The client complains of a pounding headache. The nurse should:
- A. Check the client’s blood pressure
- B. Administer the client’s ordered pain medication
- C. Place the client in a sitting position
- D. Notify the physician immediately
Correct Answer: A
Rationale: A pounding headache in a T4 spinal cord injury suggests autonomic dysreflexia, often triggered by bladder or bowel issues, causing severe hypertension. Checking blood pressure is the priority to confirm.
The nurse is caring for a client with a tracheostomy. Which action is a priority during tracheostomy care?
- A. Clean the inner cannula with sterile technique.
- B. Apply a dry dressing to the tracheostomy site.
- C. Suction the tracheostomy after cleaning.
- D. Change the tracheostomy ties daily.
Correct Answer: A
Rationale: Cleaning the inner cannula with sterile technique prevents infection and maintains airway patency, a priority. Dressings (B), suctioning (C), and tie changes (D) are secondary.
The nurse is observing the ambulation of a client recently fitted for crutches. Which observation requires nursing intervention?
- A. Two finger widths are noted between the axilla and the top of the crutch.
- B. The client bears weight on his hands when ambulating.
- C. The crutches and the client's feet move alternately.
- D. The client bears weight on his axilla when standing.
Correct Answer: D
Rationale: Bearing weight on the axilla can cause nerve damage (e.g., brachial plexus injury); crutches should support weight on the hands.
A female client is seeking counseling for personal problems. She admits to being very unhappy lately at both home and work. During the nursing assessment, she uses many defense mechanisms. Which statement or action made by the client is an example of adaptive suppression?
- A. I did not get the raise because my boss does not like me.'
- B. I felt a lump in my breast 2 weeks ago. I put off getting it checked until after my sister's wedding.'
- C. My son died 3 years ago. I still cannot bring myself to clean out his room.'
- D. My husband told me this morning that he wants a divorce. I am upset, but I cannot discuss the matter with him until after my company's board meeting today.'
Correct Answer: D
Rationale: This statement is an example of adaptive rationalization. She is coping with her disappointment by rationalizing. This is adaptive because no harm is done to self or others. It is used to protect her ego. This is an example of maladaptive suppression. She is suppressing the seriousness of the lump. It is maladaptive because delaying treatment will cause harm to her. The client's actions are an example of maladaptive denial. She is denying her son's death by not facing his possessions. Until she faces his death, she cannot face reality. This is an example of adaptive suppression. She realizes the impact of her husband's statement but delays discussion until she can devote her full attention to the matter.