Nokea
The nurse is assisting the unlicensed assistive personnel (UAP) to ambulate their clients. It would be most important for the nurse to review fall precautions with the UAP prior to ambulating the?
- A. 39-year old client who is five days post-operative from a right upper extremity amputation.
- B. 67-year-old client who is diagnosed with tuberculosis.
- C. 22-year-old client who has a new colostomy.
- D. 71-year-old client with a history of orthostatic hypotension.
Correct Answer: D
Rationale: The 71-year-old with orthostatic hypotension is at highest fall risk due to age and hypotension, requiring fall precaution review.
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The nurse is caring for a client with a sacral wound infected with Methicillin-resistant staphylococcus aureus. Which personal protective equipment (PPE) is necessary to care for this client? Select all that apply.
- A. Gloves
- B. N95 respirator
- C. Surgical Mask
- D. Goggles
- E. Gown
Correct Answer: A,E
Rationale: MRSA requires contact precautions, including gloves and a gown. N95 respirators, surgical masks, and goggles are not needed unless aerosol-generating procedures are performed.
Nurses’ Notes
1930 – Assessment completed
Peripheral pulses were all palpable. S1/S2 heart tones auscultated. No peripheral edema.
Lung sounds were clear in all fields. Client denied any cough or dyspnea. Respirations were regular and unlabored.
Bowel sounds were active in all quadrants, with no abdominal distention noted. Client only reports nausea after her prescribed acetaminophen-oxycodone.
Surgical incisions appeared approximated, reddened, and the surrounding area was hot to touch. Small amount of foul-smelling, purulent type of drainage was noted. The gauze dressing was changed, and a new gauze dressing was applied.
Client reported intermittent incisional pain of 3/10 described as ‘sore’. Vital Signs: Oral Temperature 100.4° F (38° C)
Pulse 93/minute
Respirations 18/minute
Blood pressure 111/69 mm Hg
O2 saturation 95% on room air
The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy.Select three (3) assessment and vital sign findings that are highly concerning.
- A. Incisional pain
- B. Approximated wounds
- C. Pulse rate
- D. Foul smelling drainage
- E. Nausea after pain medication
- F. Oral temperature
- G. Purulent wound drainage
Correct Answer: D,F,G
Rationale: This client is demonstrating signs and symptoms of a surgical site infection. The findings requiring follow-up include the foul-smelling drainage that is purulent. Further, this client also has a concern for their oral temperature as it is a clinical fever.
Findings that are not highly concerning include the client’s incisional pain which is described as sore and is intermittent. This is an expected finding following surgery. The wounds being approximated is an optimal finding. The client’s pulse is within normal limits. Finally, nausea after pain medication is a common side-effect.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The nurse is discussing the risk of delayed wound healing following surgery with another healthcare team member. It would be correct for the nurse to identify which condition is a potential cause of this complication?
- A. Diabetes insipidus
- B. Cushing's syndrome
- C. Hemophilia
- D. Inflammatory bowel disease
Correct Answer: B
Rationale: Cushing’s syndrome involves elevated cortisol levels, which impair wound healing by suppressing immune responses and collagen synthesis. Diabetes insipidus primarily affects fluid balance, hemophilia affects clotting but not healing directly, and inflammatory bowel disease is less directly related to wound healing compared to Cushing’s syndrome.
Item 1 of 1
• Nurses' Notes
0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.
• Medical History
• gastric bypass surgery performed two years ago
• dyslipidemia
• diabetes mellitus (type two)
• Vital Signs
• T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. wound assessment findings
- B. tolerance with activities of daily living
- C. pain in lower extremities
- D. enoxaparin self-injections
- E. pulse, respirations, and blood pressure
Correct Answer: B,C,D
Rationale: Tolerance with activities of daily living. The client reports increased difficulty with activities of daily living (ADLs) due to dyspnea, which could indicate a significant complication, such as pulmonary embolism (PE). Dyspnea, especially in the postoperative period, should always be investigated promptly, as it could be a sign of a PE, which is a life-threatening emergency. Immediate follow-up is necessary to rule out PE or other respiratory or circulatory issues. Pain in lower extremities. Pain and swelling in the lower extremities that increase with movement could suggest deep vein thrombosis (DVT). This complication is especially concerning in a postoperative patient on anticoagulation therapy (enoxaparin). DVT can lead to pulmonary embolism if the clot dislodges, which could cause dyspnea. This requires immediate follow-up to assess for DVT and initiate treatment if necessary. The client reports full adherence to postoperative enoxaparin self-injections and mentions ejecting the air bubble before injection. This is an incorrect technique; ejecting the air bubble can result in an underdose of the medication, potentially leading to ineffective anticoagulation. This can increase the risk of complications like DVT or VTE. Correct technique is crucial to ensure proper dosing. Immediate follow-up is required to educate the client about appropriate injection techniques (not ejecting the air bubble) to prevent these risks.Wound assessment findings. The transverse surgical incision is described as pink, approximated, and crusted, which are normal findings in the early postoperative period. These findings suggest no signs of infection or delayed wound healing. Therefore, no immediate follow-up is required for this finding.Incision pain level and characteristics. The client reports incisional pain at a level of 4 on the Numerical Rating Scale and increased pain when coughing. This level of pain is within a manageable range for a postoperative patient. The description of the pain as incisional and aggravated by coughing is consistent with expected postoperative discomfort. The pain level is manageable, and this is not a priority concern for immediate follow-up unless it becomes severe or is associated with other complications (e.g., infection or dehiscence).