Nokea
The nurse is caring for a client post-op femoral popliteal bypass graft. Which post-operative assessment finding would require immediate physician notification?
- A. Edema of the extremity and pain at the incision site
- B. A temperature of 99.6°F and redness of the incision
- C. Serous drainage noted at the surgical area
- D. A loss of posterior tibial and dorsalis pedis pulses
Correct Answer: D
Rationale: Loss of distal pulses indicates potential graft occlusion or arterial compromise, a surgical emergency requiring immediate notification.
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The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
- A. Hypoglycemic, small for gestational age
- B. Hyperglycemic, large for gestational age
- C. Hypoglycemic, large for gestational age
- D. Hyperglycemic, small for gestational age
Correct Answer: C
Rationale: Neonates of diabetic mothers are often large for gestational age and at risk for hypoglycemia due to maternal glucose levels.
A 4-year-old is scheduled for a routine tonsillectomy. Which of the following lab findings should be reported to the doctor?
- A. A hemoglobin of 12 Gm
- B. A platelet count of 200,000
- C. A white blood cell count of 16,000
- D. A urine specific gravity of 1.010
Correct Answer: C
Rationale: A white blood cell count of 16,000 suggests infection or inflammation, which should be reported before surgery.
The nurse caring for a client with chest tubes notes that the Pleuravac's collection chambers are full. The nurse should:
- A. Add more water to the suction-control chamber
- B. Remove the drainage using a 60 mL syringe
- C. Milk the tubing to facilitate drainage
- D. Prepare a new unit for continuing collection
Correct Answer: D
Rationale: When the Pleuravac collection chambers are full, a new unit is needed to continue effective drainage and maintain the closed system.
A client is prescribed heparin 2,000 units SC q8 hours. The pharmacy sends heparin 5,000 units/mL. How many mL should the nurse administer every 24 hours?
- A. 0.4 mL/day
- B. 0.8 mL/day
- C. 1.2 mL/day
- D. 1.4 mL/day
Correct Answer: C
Rationale: Dose per injection: 2,000 units ÷ 5,000 units/mL = 0.4 mL. Q8 hours = 3 doses/day. 0.4 mL × 3 = 1.2 mL/day.
During the nurse's assessment of a client who has been diagnosed with anorexia nervosa, the nurse evaluates certain characteristics that accompany an intense fear of gaining weight. What characteristics are most applicable? Select all that apply.
- A. fatigue
- B. excessive exercise regime
- C. normal weight
- D. high blood pressure
Correct Answer: A,B
Rationale: Fatigue and excessive exercise are common in anorexia nervosa due to malnutrition and compulsive behaviors. Normal weight or high blood pressure are less typical.