Nokea
The nurse is called to the room of a patient four days after abdominal surgery. The patient had been coughing and said he felt something give. The nurse observes that the edges of the incision have separated, and a small loop of the bowel protrudes through the incision. The nurse should position the patient
- A. with the head of the bed elevated 30°.
- B. with the foot of the bed tilted and the head of the bed down.
- C. with the head of the bed elevated 15°.
- D. with the head of the bed elevated 90°.
Correct Answer: C
Rationale: low Fowler's, reduces stress on suture line, may be placed supine with hips and knees bent
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A client has received thrombolytic therapy, and the physician has ordered meperidine (Demerol) IM for pain. Before administering the injection, the nurse should
- A. confirm that all lab work has been completed.
- B. verify the order with the physician.
- C. check the client's PTT.
- D. determine that all of the thrombolytic agent has infused.
Correct Answer: B
Rationale: implementation, complications of thrombolytic therapy include bleeding, which can occur with intramuscular injections; nurse should confer with the physician about the appropriateness of the order
The nurse plans care for a 25-year-old woman immediately after a cesarean section. Which of the following nursing goals is MOST important?
- A. Prevent infection.
- B. Prevent fluid and electrolyte imbalances.
- C. Provide for pain management.
- D. Prevent hazards of immobility.
Correct Answer: B
Rationale: hemorrhage and shock most life-threatening conditions that occur after surgery
The nurse is caring for a postoperative patient. Four hours after surgery, the patient voids 200 cc of urine with a specific gravity of 1.019. The nurse should
- A. palpate the patient's lower abdomen for distention.
- B. encourage an increased intake of oral fluids.
- C. record the time and the amount of urine.
- D. encourage the patient to void again in two hours.
Correct Answer: C
Rationale: amount and specific gravity normal (1.010-1.030)
A group of senior citizens.
The nurse teaches a health class at the local library to a group of senior citizens. Which of the following behaviors should the nurse emphasize to facilitate regular bowel elimination?
- A. Avoid strenuous activity.
- B. Eat more foods with increased bulk.
- C. Decrease fluid intake to decrease urinary losses.
- D. Use oral laxatives so that a bowel pattern emerges.
Correct Answer: B
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) regular exercise program facilitates bowel elimination (2) correct-contained in whole grains, legumes, vegetables, fruits, seeds, nuts, bulk promotes peristalsis (3) normal fluid intake of 1,500 cc/day facilitates bowel elimination (4) laxatives used as last resort because they become habit-forming
A client has a right total hip replacement. The client returns from surgery with an IV of 0.45% NaCl infusing into the left forearm at 100 cc/h. It is MOST important for the nurse to take which of the following actions?
- A. Massage the client's legs to increase circulation.
- B. Elevate the knee gatch to reduce stress on the suture line.
- C. Apply thigh-high TED hose to promote venous return.
- D. Decrease fluid intake to 1,200 cc to prevent circulatory overload.
Correct Answer: C
Rationale: use of antiembolic hose and/or sequential compression devices decreases venous stasis and reduces risk of thrombus formation