Nokea
The nurse is caring for a client who has just undergone a cholecystectomy. Which of the following positions is most appropriate for this client in the immediate postoperative period?
- A. Supine with the head of the bed flat.
- B. Semi-Fowler's position.
- C. Left lateral position.
- D. Prone position.
Correct Answer: B
Rationale: Semi-Fowler's position promotes lung expansion and reduces pressure on the surgical site after cholecystectomy.
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A client has undergone a vasectomy. The nurse instructs the client that he can begin having unprotected intercourse:
- A. When desired because sterilization is immediate.
- B. As soon as scrotal edema and tenderness resolve.
- C. When the sperm count reflects sterilization.
- D. After 6 to 10 ejaculations.
Correct Answer: C
Rationale: A vasectomy requires confirmation of azoospermia (no sperm in semen) via sperm count before unprotected intercourse to ensure sterilization, as sperm may remain in the reproductive tract initially.
A client in a cardiac rehabilitation program states that he would like to make sure he is eating the right foods to ensure adequate endurance on the treadmill. Which of the following nutrients is most helpful for promoting endurance during sustained activity?
- A. Protein.
- B. Carbohydrate.
- C. Fat.
- D. Water.
Correct Answer: B
Rationale: Carbohydrates are the primary energy source for sustained physical activity, providing glycogen stores for endurance.
A client with type 1 diabetes mellitus asks the nurse whether he can take ginseng at home. The nurse should tell the client:
- A. No, there are no therapeutic benefits of ginseng
- B. You can take the ginseng to help improve your memory
- C. You can take ginseng if you take it with a carbohydrate
- D. You should ask your physician, as ginseng may affect blood sugar levels
Correct Answer: D
Rationale: Ginseng may affect blood sugar levels, potentially interacting with diabetes management, so the client should consult their physician. Ginseng has potential benefits but requires caution in diabetes.
The nurse assesses a client with a diagnosis of rib fractures to identify the risk for potential complications. The nurse notes that the client has a history of emphysema. After the assessment, the nurse ensures that which interventions are documented in the plan of care? Select all that apply.
- A. Maintain the client in a position of comfort.
- B. Collect sputum specimens at the hour of sleep.
- C. Offer medication to suppress the cough as needed.
- D. Administer small, frequent meals with plenty of fluids.
- E. Have the client cough and breathe deeply 20 minutes after pain medication is given.
- F. Administer 4 to 6 liters of oxygen when the client's pulse oximetry drops below 90%.
Correct Answer: A,D,E
Rationale: Clients with a diagnosis of rib fractures need interventions focused on their ability to maintain an effective breathing pattern and support the body in the healing process. Breathing effort is supported when the client is maintained in a comfortable position. Giving the client small frequent meals with plenty of fluids prevents the client from doing too much eating activity at one time and provides hydration to keep sputum liquefied for easier expectoration. Giving the client prescribed pain medication first and then having the client cough and deep breathe will encourage the client to complete these actions while limiting the amount of pain from doing them. If sputum specimen collection is prescribed, the specimen should be collected early in the morning upon the client's awakening. Clients with emphysema are not given cough suppressants because expectoration of sputum is essential to airway clearance. Giving the client with emphysema a high flow of oxygen could halt the hypoxic drive and cause apnea. A prescription is needed for changes in the oxygen flow.
The nurse assesses a client scheduled for a thyroidectomy for psychosocial problems that may cause preoperative anxiety. Considering the nature of the surgery which client fear is a realistic source of anxiety?
- A. Sexual dysfunction and infertility
- B. Imposed dietary restrictions after discharge
- C. Developing gynecomastia and hirsutism postoperatively
- D. Changes in body image secondary to the location of the incision
Correct Answer: D
Rationale: Because the incision is in the neck area, the client may be fearful of having a large scar postoperatively. Sexual dysfunction and infertility could possibly occur if the entire thyroid gland is removed, and the client is not placed on thyroid replacement medications. The client will not have specific dietary restrictions after discharge. Having all or part of the thyroid gland removed will not cause gynecomastia or hirsutism.