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The nurse is caring for a client who had an orthopedic injury of the leg that required surgery and the application of a cast. Postoperatively, which nursing assessment is of highest priority to assure client safety?
- A. Monitoring for heel breakdown
- B. Monitoring for bladder distention
- C. Monitoring for extremity shortening
- D. Monitoring for blanching ability of toe nail beds
Correct Answer: D
Rationale: With cast application, concern for compartment syndrome development is of the highest priority. If postsurgical edema compromises circulation, the client will demonstrate numbness, tingling, loss of blanching of toenail beds, and pain that will not be relieved by opioids. Although heel breakdown, bladder distention, or extremity lengthening or shortening can occur, these complications are not potentially life-threatening complications.
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A client experiencing empyema is to have a bedside thoracentesis performed. The nurse plans to have which equipment available in the event that the procedure is not effective?
- A. Code cart
- B. A small-bore needle
- C. Extra-large drainage bottle
- D. Chest tube and drainage system
Correct Answer: D
Rationale: Empyema is the collection of pus within the pleural cavity. If the exudate is too thick for drainage via thoracentesis, the client may require placement of a chest tube to adequately drain the purulent effusion. A small-bore needle would not effectively allow exudate to drain. Options 1 and 3 are also unnecessary.
A client has not ingested any food or liquids for 4 hours after two episodes of nausea and vomiting. What will the nurse offer the client initially now that she or he is no longer nauseated?
- A. Toast
- B. Gelatin
- C. Dry cereal
- D. Ginger ale
Correct Answer: D
Rationale: Clear liquids are best tolerated first after episodes of nausea and vomiting. If the client tolerates sips (20 to 30 mL at a time) of clear liquids, such as water or ginger ale (with the carbonation removed if better tolerated), then the amounts may be increased and gelatin, tea, and broth may be added. Once these are tolerated, solid foods such as toast, cereal, chicken, and other easily digested foods may be tried.
After a client diagnosed with pleural effusion had a thoracentesis, a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. Based on this test result, what was the cause of this client's pleural effusion?
- A. Trauma
- B. Infection
- C. Liver failure
- D. Heart failure
Correct Answer: A
Rationale: Pleural fluid from an effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.
The nurse reviews a primary health care provider's prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Headache is a common side effect of nitrates.
- B. Fever usually accompanies myocardial infarction.
- C. Acetaminophen potentiates the therapeutic effect of nitrates.
- D. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
Correct Answer: A
Rationale: Headache occurs as a side effect of nitrates in many clients. Acetaminophen may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.
The nurse in the prenatal clinic is monitoring a client who is pregnant with twins. The nurse monitors the client closely for which priority complication that is associated with a twin pregnancy?
- A. Hemorrhoids
- B. Postterm labor
- C. Maternal anemia
- D. Costovertebral angle tenderness
Correct Answer: C
Rationale: Maternal anemia often occurs in twin pregnancies because of a greater demand for iron by the fetuses. Options 1 and 4 occur in a twin pregnancy but would not be as high a priority as anemia. Option 2 is incorrect because twin pregnancies often end in prematurity.