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The nurse is caring for a client two days post-operative following gastroduodenostomy. After reviewing the clinical data, the nurse should take which action?
- A. obtain a prescription for an antihypertensive
- B. determine if the client's pain is being controlled
- C. assess the client's surgical wound for signs of infection
- D. notify the physician for concerns of hypovolemic shock
Correct Answer: D
Rationale: Without specific clinical data, the priority for a client two days post-gastroduodenostomy is to assess for hypovolemic shock, a potential complication due to bleeding or fluid loss from the surgical site. This is more urgent than pain control, wound infection assessment, or antihypertensive needs, which require specific clinical indicators.
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The nurse is caring for an older adult following a total hip arthroplasty. The nurse should anticipate a prescription for which postoperative medication?
- A. Hydrocortisone
- B. Enoxaparin
- C. Metoprolol
- D. Furosemide
- E. Morphine
Correct Answer: B,E
Rationale: Enoxaparin prevents venous thromboembolism, a common risk post-hip arthroplasty, and morphine manages postoperative pain. Hydrocortisone, metoprolol, and furosemide are not routinely prescribed unless indicated by specific conditions.
The nurse is performing a home safety assessment for an older adult. What environmental factors should be considered when assessing the client for risk for falls?
- A. Cognitive impairment
- B. Vision loss
- C. Hearing loss
- D. Adequate lighting
Correct Answer: B,D
Rationale: Vision loss and inadequate lighting are environmental factors increasing fall risk. Cognitive and hearing impairments are client-specific, not environmental.
The nurse is part of an infection control committee that is responding to an outbreak of norovirus in the long-term care facility. Which recommendation should the nurse make to prevent further transmission of this outbreak?
- A. Clients wear surgical masks while ambulating in the hallway.
- B. Replace boxes of clean gloves with sterile gloves.
- C. Review hand hygiene expectations with dietary staff.
- D. Screen visitors for any respiratory symptoms such as cough or fever.
Correct Answer: C
Rationale: Norovirus spreads via fecal-oral route, so reinforcing hand hygiene, especially among dietary staff, is critical. Masks, sterile gloves, and respiratory screening are less relevant.
The nurse is discussing infection control with a group of nursing students. Which indication would be appropriate for the nurse to use an alcohol-based sanitizer? Select all that apply.
- A. Immediately before touching a client
- B. After applying sterile gloves
- C. When changing linens for a client infected with Clostridium difficile
- D. After changing a diaper for an infant infected with norovirus
- E. After collecting vital signs on a client with human immunodeficiency virus (HIV)
Correct Answer: A,E
Rationale: Alcohol-based sanitizers are effective before touching a client and after non-soiled contact like vital signs for HIV. They are ineffective for C. difficile or norovirus, and hand washing is needed after applying gloves.
The nurse is caring for a client who has severe burns on their right arm and is in pain despite receiving a prescribed pain medication. The nurse decides to rub the client's uninjured left arm to relieve pain in the right. This approach is called
- A. Biofeedback.
- B. Contralateral stimulation.
- C. Transcutaneous electrical nerve stimulator (TENS).
- D. Acupressure.
Correct Answer: B
Rationale: Contralateral stimulation involves stimulating the opposite side to reduce pain perception, effective for some pain types. Biofeedback, TENS, and acupressure are different modalities.