Nokea
The nurse is caring for a client who had a total gastrectomy performed this morning. When the client returns to the nursing care unit, the drainage from the nasogastric tube is red. What is the nurse's best response to this?
- A. Report it immediately to the charge nurse or the physician
- B. Record the finding and continue to observe
- C. Immediately apply pressure to the operative site
- D. Place the client in Trendelenburg position
Correct Answer: A
Rationale: Red nasogastric drainage post-gastrectomy suggests bleeding, requiring immediate reporting to assess for hemorrhage.
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The nurse returns to the nurse's station after making client rounds and finds four phone messages.
Which of the following messages should the nurse return FIRST?
- A. A client with hepatitis A who states, 'My arms and legs are itching.'
- B. A client with a cast on the right leg who states, 'I have a funny feeling in my right leg.'
- C. A client with osteomyelitis of the spine who states, 'I am so nauseous that I can't eat.'
- D. A client with arthritis who states, 'I am having trouble sleeping at night.'
Correct Answer: B
Rationale: Strategy: Eliminate the most stable clients. (1) caused by accumulation of bile salts under the skin; treat with calamine lotion and antihistamines (2) correct-may indicate neurovascular compromise; requires immediate assessment (3) requires follow-up but not highest priority (4) requires assessment but not the highest priority
A client admitted with acute hypoparathyroidism.
It is MOST important for the nurse to have which of the following items available?
- A. Tracheostomy set.
- B. Cardiac monitor.
- C. IV monitor.
- D. Heating pad.
Correct Answer: A
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) correct-tracheostomy set is the most important for the client's safety due to risk for laryngospasm (2) nice to have, but not the most important (3) nice to have, but not the most important (4) unnecessary
The nurse is caring for a client with a history of anxiety who is receiving lorazepam (Ativan) 0.5 mg PO tid. Which of the following client statements would be of GREATest concern to the nurse?
- A. I feel drowsy in the morning.
- B. I have a dry mouth.
- C. I feel dizzy when I stand up.
- D. I take my medication with food.
Correct Answer: C
Rationale: Dizziness upon standing suggests orthostatic hypotension, a serious side effect of lorazepam, increasing fall risk and requiring evaluation. Options A, B, and D are less concerning: drowsiness and dry mouth are common, and taking with food is acceptable.
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Continue to monitor the client to see if the bubbling increases
- D. Instruct the client to try to avoid coughing
Correct Answer: C
Rationale: Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.
What are two major side effects of haloperidol (Haldol) the nurse should anticipate?
- A. Blood dyscrasia and extrapyramidal symptoms.
- B. Hearing loss and unsteady gait.
- C. Nystagmus and vertical gaze palsy.
- D. Alteration in level of consciousness and increased confusion.
Correct Answer: A
Rationale: major side effects of haloperidol (Haldol) include hematologic problems, primarily blood dyscrasia and extrapyramidal symptoms (EPS)