Nokea
The nurse is caring for a client immediately postoperative following a below-the-knee amputation. The nurse should take which priority action?
- A. Elevate the stump on a pillow
- B. Check the operative site for bleeding
- C. Obtain an order for a physical therapy order
- D. Demonstrate the use of incentive spirometry (IS)
Correct Answer: B
Rationale: Checking the operative site for bleeding is the priority to detect hemorrhage, a life-threatening complication in the immediate postoperative period. Elevating the stump may be contraindicated to prevent contractures, physical therapy orders are not immediate, and incentive spirometry, while important, is secondary to hemorrhage control.
You may also like to solve these questions
The occupational health nurse is teaching a group of unlicensed assistive personnel how to practice appropriate ergonomics. It would be appropriate for the nurse to recommend that
- A. your feet are firmly on the floor while you are sitting in a chair
- B. Your feet are close together as you move or transfer a client.
- C. heavy objects are held far away from your body to achieve balance.
- D. you should squat to lift objects off of the ground.
- E. your neck should be extended as you look at the computer monitor.
Correct Answer: A,D
Rationale: Feet on the floor and squatting to lift reduce strain. A wide stance, holding objects close, and neutral neck position are correct ergonomic practices.
The nurse is caring for assigned clients. Which essential infection control measure should the nurse take?
- A. Perform hand hygiene before, after, and between providing direct client care
- B. Wear gloves while providing client care
- C. Cleanse equipment such as thermometers or stethoscopes between client care
- D. Maintain a distance of 3 feet away from clients who are coughing
Correct Answer: A
Rationale: Hand hygiene is the most essential infection control measure to prevent pathogen transmission.
The nurse is applying soft wrist restraints to a client who is violent towards the nursing staff. Which actions by the nurse are appropriate? Select all that apply.
- A. Places a pair of scissors at the bedside for emergent discontinuation.
- B. Positions the client supine after applying both wrist restraints.
- C. Releases both restraints at the same time, every two hours.
- D. Informs the client of the behavior necessary to demonstrate to end the restraints.
- E. Ensures two fingers can be placed under each restraint.
Correct Answer: D,E
Rationale: Informing the client of expected behavior and ensuring a two-finger gap promote safety and compliance. Scissors are unsafe, supine positioning is not required, and simultaneous release is impractical.
The nurse prepares a client for a positron emission tomography (PET) scan. Which laboratory data is necessary to obtain before this test?
- A. Urine specific gravity
- B. Liver function tests
- C. Blood glucose
- D. Creatine kinase
Correct Answer: C
Rationale: PET scans often use glucose-based tracers, so blood glucose levels must be checked to ensure accurate imaging. Other labs are not routinely required.
The perioperative nurse is documenting a client's current health status. It would be correct for the nurse to document the client's current position as: See the image in the exhibit.
- A. Prone
- B. Supine
- C. Trendelenburg position
- D. The Sims’ position
Correct Answer: C
Rationale: This picture shows the Trendelenburg position. The body is laid supine or flat on the back on a 15-30 degree incline with the feet elevated above the head. The Trendelenburg position increases the venous blood return to the heart when a client is affected by hypotension, hypovolemia, or shock. This position also improves spinal anesthesia's effects and prevents air embolism during central venous cannulation