Nokea
The nurse is caring for a child immediately after surgical correction of a ventricular septal defect. Which of the following nursing assessments should be a priority?
- A. Blanch nail beds for color and refill
- B. Assess for post-operative arrhythmias
- C. Auscultate for pulmonary congestion
- D. Monitor equality of peripheral pulses
Correct Answer: B
Rationale: Assess for post-operative arrhythmias. The atrioventricular bundle (bundle of His), a part of the electrical conduction system of the heart, extends from the atrioventricular node along each side of the interventricular septum and then divides into right and left bundle branches. Surgical repair of a ventricular septal defect consists of a purse-string approach or a patch sewn over the opening.
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A nurse is observing a client during an excretory urogram. Which of these observations indicate a complication is occurring?
- A. The client complains of a salty taste in the mouth when the dye is injected.'
- B. The client's entire body turns a bright red color.'
- C. The client states 'I have a feeling of getting warm.''
- D. The client gags and complains 'I am getting sick.''
Correct Answer: B
Rationale: The client's entire body turns a bright red color.' This observation suggests anaphylaxis which results in massive vasodilation. Other findings would be immediate wheezing and/or respiratory arrest.
When caring for a client with a post-right thoracotomy who has undergone an upper lobectomy, the nurse focuses on pain management to promote
- A. relaxation and sleep
- B. deep breathing and coughing
- C. incisional healing
- D. range of motion exercises
Correct Answer: B
Rationale: The priority is preventing postoperative respiratory complications. This client will quickly develop profound atelectasis and eventually pneumonia without adequate gas exchange. Client compliance with recommended deep breathing and coughing exercises will only be achieved with the appropriate pain management.
The client who is receiving TPN through a subclavian triple-lumen catheter expresses concern to the nurse about bacteria entering the blood through the catheter. The nurse explains that the risk of catheter-related infections can be decreased by taking which action?
- A. Applying an antibiotic ointment at the catheter insertion site daily
- B. Changing the dressing over the catheter insertion site every day
- C. Designating one port of the catheter exclusively for the TPN solution
- D. Instilling an antibiotic solution daily into each port of the catheter
Correct Answer: C
Rationale: C: Using one port exclusively for TPN reduces infection risk by limiting access points. A, D: Antibiotic use risks resistance. B: Daily dressing changes are unnecessary unless soiled.
The HCP documents that the client has a generalized infection. Which specific assessment finding should the nurse expect?
- A. Redness and warmth at the site
- B. Swelling and pain at the site
- C. Hypertension and bradycardia
- D. Fever and widespread muscle aches
Correct Answer: D
Rationale: D: Generalized infections cause systemic symptoms like fever and muscle aches. A, B: These are localized signs. C: Hypotension and tachycardia are more likely.
A client in a long term care facility complains of pain. The nurse collects data about the client's pain. The first step in pain assessment is for the nurse to
- A. have the client identify coping methods
- B. get the description of the location and intensity of the pain
- C. accept the client's report of pain
- D. determine the client's status of pain
Correct Answer: C
Rationale: accept the client's report of pain. Although all of the options above are correct, the first and most important piece of information in this client's pain assessment is what the client is telling you about the pain -- 'the client's report.'