Nokea
The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
- A. Administer IV fluid bolus as prescribed by the healthcare provider.
- B. Encourage the client to splint the Incision with a pillow to cough and deep breathe.
- C. Medicate for pain and monitor vital signs according to protocol.
- D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: C
Rationale: Pain medication addresses tachycardia and tachypnea likely caused by postoperative pain, stabilizing vital signs.
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A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Administer pain medication at designated Intervals around the clock.
- B. Assess the pulses proximal to the fracture site.
- C. Remove traction every shift and provide skin care.
- D. Assess the pin sites for signs of infection.
Correct Answer: D
Rationale: Assessing pin sites for infection is critical in skeletal traction to prevent complications like osteomyelitis, which could delay healing.
A client is admitted to the hospital for treatment of a simple goiter, and levothyroxine sodium is prescribed. Which symptoms indicate to the nurse that the prescribed dosage is too high for this client?
- A. Bradycardia and constipation.
- B. Lethargy and lack of appetite.
- C. Muscle cramping and dry, flushed skin.
- D. Palpitations and shortness of breath.
Correct Answer: D
Rationale: Palpitations and shortness of breath indicate hyperthyroidism from excessive levothyroxine, requiring dosage adjustment.
Imaging Studies
Day 1, 1100
X-ray of right foot erosion of first metatarsal joint and preservation of joint space consistent with gout
The nurse is reviewing the client's dietary choices for opportunities to pro better outcomes by limiting gout attacks
Select the 3 dietary choices that are not part of the recommended diet gout.
- A. Shrimp
- B. Sardines
- C. Quinoa
- D. Oranges
- E. Oatmeal
- F. Spinach
- G. Liver
Correct Answer: A,B,G
Rationale: Shrimp , sardines , and liver are high in purines, which increase uric acid levels and should be avoided in gout management.
A college student comes to the school's health clinic troubled by urinary frequency and burning with right lower back pain. Which intervention should the nurse implement first?
- A. Palpate the right flank for tenderness.
- B. Evaluate the urine for a strong odor.
- C. Test the urine for the presence of hematuria.
- D. Measure the temperature and pulse rate.
Correct Answer: D
Rationale: Measuring temperature and pulse assesses for systemic infection, such as pyelonephritis, which is urgent given the symptoms.
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
- A. Reduce intake of fatty foods.
- B. Chew slowly and thoroughly.
- C. Eat small frequent meals.
- D. Sip fluids with each meal.
Correct Answer: C
Rationale: Small, frequent meals prevent stomach pouch stretching and dumping syndrome, optimizing nutrient absorption.