Nokea
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct Answer: C
Rationale: The correct answer is C: Ineffective peripheral tissue perfusion. This is the most important nursing diagnosis because after abdominal aortic aneurysm repair, there is a risk of compromised blood flow to peripheral tissues due to potential complications like embolism or thrombosis. Monitoring tissue perfusion is crucial to prevent complications such as tissue necrosis.
A: Risk for infection is important but not the priority immediately postoperatively.
B: Deficient knowledge may be addressed later once the client is stable.
D: Activity intolerance may be a concern but ensuring tissue perfusion is more critical in the immediate postoperative period.
In summary, monitoring and addressing ineffective peripheral tissue perfusion is essential for preventing serious complications following abdominal aortic aneurysm repair.
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The nurse is doing preoperative teaching with the client who is about to undergo creation of a Kock pouch. The nurse interprets that the client has the best understanding of the nature of the surgery if the client makes which of the following statements?
- A. I will need to drain the pouch regularly with a catheter.
- B. I will need to wear a drainage bag for the rest of my life.
- C. The drainage from this type of ostomy will be formed.
- D. I will be able to pass stool from the rectum eventually.
Correct Answer: A
Rationale: The correct answer is A: "I will need to drain the pouch regularly with a catheter." This answer demonstrates an accurate understanding of the Kock pouch procedure, which involves the creation of a reservoir that needs to be drained periodically to prevent complications like overflow or infection.
Rationale:
1. A Kock pouch is a continent ileostomy that requires regular catheterization for drainage.
2. Choice B is incorrect because wearing a drainage bag for life is not necessary with a Kock pouch.
3. Choice C is incorrect as a Kock pouch does not produce formed drainage.
4. Choice D is incorrect because passing stool from the rectum is not possible after a Kock pouch surgery.
In summary, choice A is the correct answer as it aligns with the specific care requirements of a Kock pouch surgery, while the other options misrepresent the nature of the procedure.
During an abdominal assessment, a nurse finds pulsation between the umbilicus and pubis on a client. What finding should be reported to the physician?
- A. Concave, midline umbilicus
- B. Pulsation between the umbilicus and pubis
- C. Bowel sound frequency of 15 sounds per minute
- D. Absence of a bruit
Correct Answer: B
Rationale: The correct answer is B because pulsation between the umbilicus and pubis could indicate an abdominal aortic aneurysm (AAA), a serious condition that requires immediate medical attention. The pulsation in this area could be the enlargement of the aorta, which can be life-threatening if it ruptures. Reporting this finding to the physician is crucial for further evaluation and intervention.
Choice A (Concave, midline umbilicus) is incorrect because it is a normal finding during an abdominal assessment. Choice C (Bowel sound frequency of 15 sounds per minute) is incorrect as it falls within the normal range of bowel sounds. Choice D (Absence of a bruit) is also incorrect as the absence of a bruit is a normal finding and does not indicate any immediate concern.
A nurse is caring for a client who has just returned from the operating room following the creation of a colostomy. The nurse is assessing the drainage in the pouch attached to the site where the colostomy was formed and notes serosanguineous drainage. Which nursing action is most appropriate based on this assessment?
- A. Notify the physician
- B. Document the amount and characteristics of the drainage
- C. Apply ice to the stoma site
- D. Apply pressure to the site
Correct Answer: B
Rationale: The correct answer is B: Document the amount and characteristics of the drainage. This is appropriate as serosanguineous drainage is expected after colostomy creation. Documenting helps monitor for any changes and provides crucial information for the healthcare team.
Choice A (Notify the physician) is not necessary at this point as serosanguineous drainage is normal postoperatively. Choice C (Apply ice to the stoma site) and Choice D (Apply pressure to the site) are both incorrect actions that are not indicated in this situation and could potentially harm the client.
Which of the following nursing interventions should have the highest priority during the first hour after the admission of a client with cholecystitis who is experiencing pain, nausea, and vomiting?
- A. Administering pain medication.
- B. Completing the admission history.
- C. Maintaining hydration.
- D. Teaching about planned diagnostic tests.
Correct Answer: A
Rationale: The correct answer is A: Administering pain medication. Immediate pain relief is crucial in managing cholecystitis symptoms and improving the client's comfort. Pain can lead to increased stress, anxiety, and physiological responses that can worsen the condition. Administering pain medication promptly can help alleviate these symptoms and allow the client to rest. Completing the admission history (B) is important but can be done after addressing the urgent pain and discomfort. Maintaining hydration (C) is also essential but may not be the highest priority compared to pain relief. Teaching about planned diagnostic tests (D) is important for the client's understanding but can be deferred until the pain and discomfort are managed effectively.
A client with viral hepatitis is discussing with the nurse the need to avoid alcohol and states, 'I'm not sure I can avoid alcohol.' The most appropriate response is
- A. Everything will be alright.
- B. I think you should talk more with the doctor about this.
- C. I don't believe that.
- D. I'm not sure that I don't understand. Would you please explain?
Correct Answer: D
Rationale: The correct answer is D because it shows active listening and empathy towards the client's concerns. By asking the client to explain, the nurse can gain a better understanding of the client's perspective and provide tailored support and information. Choice A is incorrect as it dismisses the client's concerns. Choice B is incorrect as it deflects responsibility from the nurse. Choice C is incorrect as it shows disbelief and lacks empathy.