Nokea
The nurse is caring for a client three hours postoperative following a laparoscopic appendectomy. Which of the following client data indicates the client is ready for discharge home?
- A. Positive gag reflex
- B. Hypoactive bowel sounds
- C. Blood pressure 90/60 mm Hg
- D. Incisional pain '2' on a scale of 0 to 10
- E. Urinary output of 240 mL since surgery
Correct Answer: A,D,E
Rationale: A positive gag reflex indicates airway protection, mild incisional pain (2/10) suggests adequate pain control, and sufficient urinary output (240 mL) indicates renal function, all supporting discharge readiness. Low blood pressure (90/60 mm Hg) suggests instability, and hypoactive bowel sounds are expected but not a discharge criterion.
You may also like to solve these questions
The nurse cares for geriatric clients. What would the nurse emphasize as an increased risk for this client population?
- A. Blepharitis and chalazion
- B. Myopia and strabismus
- C. Exophthalmos and presbyopia
- D. Glaucoma and cataracts
Correct Answer: D
Rationale: Glaucoma and cataracts are common age-related eye conditions, increasing vision loss risk. Other conditions are less prevalent or age-specific.
The nurse is performing a fall risk assessment on a group of clients. It would be appropriate for the nurse to identify the client at risk for falls who. Select all that apply.
- A. Is an older adult.
- B. Has a history of two previous falls
- C. Taking oral antibiotics.
- D. Experiences postural hypotension.
- E. Wearing non-slip shoes.
Correct Answer: A,B,D
Rationale: Older adults, those with prior falls, and postural hypotension increase fall risk. Oral antibiotics and non-slip shoes do not contribute to fall risk.
The nurse is reviewing medical-surgical concepts with a group of nursing students. When discussing pain, it is appropriate for the nurse to categorize pain that occurs with short duration as
- A. Chronic pain
- B. Acute pain.
- C. Referred pain.
- D. Neuropathic pain.
Correct Answer: B
Rationale: Acute pain is short-duration, typically linked to injury or surgery. Chronic pain is persistent, referred pain is felt elsewhere, and neuropathic pain involves nerve damage.
The nurse is planning care for a pediatric client being admitted with pulmonary tuberculosis (TB). Which of the following interventions should the nurse include in the client's plan of care?
- A. consult the infection control nurse
- B. room the client with an uninfected client 6 feet apart
- C. place the client with another client who has varicella in the shared airborne isolation room 6 feet apart
- D. place the client in a private room with monitored positive airflow
Correct Answer: A
Rationale: Consulting the infection control nurse ensures proper airborne precautions for TB. Cohorting or positive airflow is inappropriate.
The nurse is assessing a client who just returned from surgery. The nurse checks preoperative vital signs at 0830 to compare them with the current vital signs at 1030 . What action should the nurse take?
- A. Assess the surgical wound
- B. Collect blood cultures
- C. Administer oxygen at 2 L/minute
- D. Encourage by-mouth (PO) fluids
Correct Answer: C
Rationale: Changes in vital signs post-surgery may indicate respiratory or circulatory compromise. Administering oxygen at 2 L/minute is a prudent initial action to support oxygenation while further assessment occurs. Wound assessment, blood cultures, or fluids require specific clinical indications.