Nokea
The nurse is caring for a client who has soft-limb wrist restraints applied. The highest priority for the nurse is to
- A. Provide the client with opportunities to discuss their feelings.
- B. Document the neurovascular assessments.
- C. Assess the client's mood and affect.
- D. Offer nutrition and hydration.
Correct Answer: B
Rationale: Neurovascular assessments ensure circulation and safety, the highest priority with restraints. Other actions are important but secondary.
You may also like to solve these questions
The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when
- A. Meeting resistance.
- B. As soon as urine is observed in the tubing.
- C. After advancing to the point of bifurcation.
- D. After fully advancing the length of the catheter.
Correct Answer: C
Rationale: The balloon should be inflated after advancing the catheter to the bifurcation (Y-connector), ensuring it is in the bladder. Inflating too early or fully advancing risks trauma or improper placement.
Nurses’ Notes
1930 – Assessment completed
Peripheral pulses were all palpable. S1/S2 heart tones auscultated. No peripheral edema.
Lung sounds were clear in all fields. Client denied any cough or dyspnea. Respirations were regular and unlabored.
Bowel sounds were active in all quadrants, with no abdominal distention noted. Client only reports nausea after her prescribed acetaminophen-oxycodone.
Surgical incisions appeared approximated, reddened, and the surrounding area was hot to touch. Small amount of foul-smelling, purulent type of drainage was noted. The gauze dressing was changed, and a new gauze dressing was applied.
Client reported intermittent incisional pain of 3/10 described as ‘sore’. Vital Signs: Oral Temperature 100.4° F (38° C)
Pulse 93/minute
Respirations 18/minute
Blood pressure 111/69 mm Hg
O2 saturation 95% on room air
The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy.Select three (3) assessment and vital sign findings that are highly concerning.
- A. Incisional pain
- B. Approximated wounds
- C. Pulse rate
- D. Foul smelling drainage
- E. Nausea after pain medication
- F. Oral temperature
- G. Purulent wound drainage
Correct Answer: D,F,G
Rationale: This client is demonstrating signs and symptoms of a surgical site infection. The findings requiring follow-up include the foul-smelling drainage that is purulent. Further, this client also has a concern for their oral temperature as it is a clinical fever.
Findings that are not highly concerning include the client’s incisional pain which is described as sore and is intermittent. This is an expected finding following surgery. The wounds being approximated is an optimal finding. The client’s pulse is within normal limits. Finally, nausea after pain medication is a common side-effect.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.
The nurse is caring for a client who has been on bed rest for 2 days following surgery. To prevent complications associated with the client's first ambulation, the nurse should plan to
- A. Encourage the client to increase fluid intake to at least 2,000 mL per day.
- B. Assist the client in performing range-of-motion (ROM) exercises.
- C. Teach the client how to use the incentive spirometer.
- D. Encourage the client to dangle their legs at the bedside.
Correct Answer: D
Rationale: Dangling legs at the bedside prevents orthostatic hypotension during first ambulation. Fluids, ROM, and spirometry are supportive but not specific to ambulation.
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.