Nokea
The nurse is caring for a client who has just undergone a coronary artery bypass graft (CABG). Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bleeding.
- B. Encourage deep breathing exercises.
- C. Administer oral pain medications.
- D. Restrict all visitors.
Correct Answer: A
Rationale: Monitoring for bleeding is critical post-CABG due to the risk of hemorrhage from the surgical site or anticoagulation therapy.
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A client returns to the recovery room following left supratentorial surgery for treatment of a brain tumor. The nurse should place the client in which position to facilitate venous drainage?
- A. Lying flat without a pillow with his head turned to the right.
- B. Lying flat with his head elevated on three pillows.
- C. Head of the bed elevated to 30 degrees with his head in a neutral position.
- D. Side-lying on his left side.
Correct Answer: C
Rationale: The head of the bed should be elevated 30 degrees to promote venous drainage and decrease intracranial pressure. The client's head should be in a midline, or neutral, position. Clients with supratentorial surgery should be positioned on the nonoperative side to prevent displacement of the cranial contents by gravity.
The nurse is teaching a client with a new ileostomy about dietary modifications. Which food should be avoided?
- A. Rice.
- B. Corn.
- C. Bananas.
- D. Yogurt.
Correct Answer: B
Rationale: Corn is high in fiber and hard to digest, which can cause blockages in a new ileostomy.
A client has atrial fibrillation. The nurse should monitor the client for:
- A. Cardiac arrest
- B. Cerebrovascular accident
- C. Heart block
- D. Ventricular fibrillation
Correct Answer: B
Rationale: Atrial fibrillation increases the risk of thromboembolism, leading to cerebrovascular accident (stroke). Cardiac arrest, heart block, and ventricular fibrillation are less directly associated.
The nurse monitors the serum electrolyte levels of a client who is taking digoxin (Lanoxin). Which of the following electrolyte imbalances is a common cause of digoxin toxicity?
- A. Hyponatremia.
- B. Hypomagnesemia.
- C. Hypocalcemia.
- D. Hypokalemia.
Correct Answer: D
Rationale: Hypokalemia enhances digoxin's effect on the heart, increasing toxicity risk by altering cardiac membrane potential.
A client with a history of schizophrenia is prescribed ziprasidone (Geodon). The nurse should monitor the client for which of the following adverse effects?
- A. Prolonged QT interval.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Weight loss.
Correct Answer: A
Rationale: Ziprasidone can cause prolonged QT interval, increasing arrhythmia risk.