Nokea
The nurse is assessing a client's left leg for neurovascular changes following a total left knee replacement. Which of the following are expected normal findings? Select all that apply.
- A. Reduced edema of the left knee.
- B. Skin warm to touch.
- C. Capillary refill response.
- D. A 55-year-old response.
- E. Pain absent.
- F. Pulse on left leg weaker than right leg.
Correct Answer: A,B,C
Rationale: Reduced edema, warm skin, and normal capillary refill are expected post-surgery. Pain is typically present, and pulses should be equal.
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What is the nurse's priority when a client experiences a seizure?
- A. Restrain the client.
- B. Protect the airway.
- C. Administer oxygen.
- D. Record the duration.
Correct Answer: B
Rationale: Protecting the airway is the priority to ensure oxygenation during a seizure.
A client who had a gastrectomy has been in the postanesthesia recovery room for 30 minutes when his vital signs suddenly change. In addition to notifying the physician, what other action should the nurse take immediately?
- A. Administer oxygen.
- B. Elevate the head of the bed 30 degrees.
- C. Administer a bolus of I.V. fluids.
- D. Insert an indwelling urinary catheter.
Correct Answer: A
Rationale: Sudden vital sign changes post-gastrectomy suggest hypoxia or shock. Administering oxygen addresses potential respiratory compromise, a common postoperative issue, while awaiting physician guidance.
A 36-year-old male with lymphoma is assessing a client who reports distress 9 days after chemotherapy. Because of the risk for septic shock, the nurse should assess the client for which cluster of symptoms?
- A. Flushing, decreased oxygen saturation, mild hypotension.
- B. Low-grade fever, chills, tachycardia.
- C. Elevated temperature, oliguria, hypotension.
- D. High-grade fever, normal blood pressure, increased respirations.
Correct Answer: C
Rationale: Elevated temperature, oliguria, and hypotension are critical signs of septic shock, a life-threatening complication in chemotherapy patients due to neutropenia.
While changing the client's colostomy bag and dressing, the nurse assesses that the client is ready to participate in her care by noting which of the following?
- A. The client asks what time the doctor will visit that day.
- B. The client asks about the supplies used during the dressing change.
- C. The client talks about something she read in the morning newspaper.
- D. The client complains about the way the night nurse changed the dressing.
Correct Answer: B
Rationale: The client's inquiry about the supplies used during the dressing change indicates interest and readiness to participate in her colostomy care. Other options reflect unrelated concerns or dissatisfaction, not readiness to engage in self-care. CN: Psychosocial adaptation; CL: Evaluate
A client is beginning external beam radiation therapy to the right axilla after a lumpectomy for breast cancer. Which of the following should the nurse include in client teaching?
- A. Use a heating pad under the right arm.
- B. Place ice on the area after each treatment.
- C. Apply deodorant only under the left arm.
- D. Use a soft washcloth to gently cleanse the area.
Correct Answer: C
Rationale: Applying deodorant only under the left arm avoids irritation to the radiated right axilla, which is sensitive and prone to skin reactions during treatment.