Nokea
The nurse is assessing a client who had gastric bypass surgery two days ago. The nurse should prioritize assessing the client for
- A. venous thromboembolism
- B. their current weight
- C. nausea and vomiting
- D. surgical site infection
Correct Answer: C
Rationale: Nausea and vomiting are priority assessments post-gastric bypass due to the risk of anastomotic leaks or obstruction, which can be life-threatening. Venous thromboembolism and surgical site infection are concerns but less immediate, and weight assessment is not a priority at this stage.
You may also like to solve these questions
The nurse is observing a client ambulate with a walker. It would require follow-up by the nurse if the client
- A. Advances the walker 6-10 inches.
- B. Has their elbow flexed 15-30 degrees.
- C. Tilts the walker forward to help stand up from a chair.
- D. Advances the walker and then the affected leg.
Correct Answer: C
Rationale: Tilting the walker forward to stand is unsafe, risking falls. Advancing 6-10 inches, 15-30 degree elbow flexion, and proper stepping sequence are correct.
The nurse is caring for a client with a port. Which of the following actions would be appropriate to take? Select all that apply.
- A. Access the port using sterile technique.
- B. Flush the port with heparin prior to de-access.
- C. Access the port using a 16-gauge catheter.
- D. Have the client wear a mask during the dressing change.
- E. Aspirate for blood return prior to medication administration.
Correct Answer: A,B,E
Rationale: Sterile technique, heparin flushing, and aspirating for blood return are standard for port care. A 16-gauge catheter is too large, and a client mask is unnecessary.
The nurse is developing a plan of care for a client with pertussis. It would be appropriate for the nurse to include which interventions? Select all that apply.
- A. Wear a surgical mask when working within three feet of the client
- B. Provide disposable dishes for meals
- C. Keep the client's room door closed
- D. Provide the client with a portable fan
- E. Maintain negative air pressure
- F. Apply a N95 mask to the client during transport
- G. Place the client in a room near the nurse's station
Correct Answer: A,C,F
Rationale: Pertussis requires droplet precautions: surgical mask within 3 feet, closed door, and N95 for transport. Disposable dishes, fans, and negative pressure are not needed.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.
The nurse assesses a client who requires bilateral wrist restraints for agitation and hostility toward staff. When performing follow-up assessments, what data is necessary for the nurse to obtain? Select all that apply.
- A. previous restraint use
- B. skin integrity
- C. behavioral status
- D. vital signs
- E. urinary continence
Correct Answer: B,C,D
Rationale: Skin integrity, behavioral status, and vital signs must be assessed regularly to ensure safety, monitor for complications, and evaluate the ongoing need for restraints.