Nokea
The nurse is caring for a client who is describing pain on their hand as 'throbbing and sharp.' Which type of pain is the client experiencing based on this sensory description?
- A. Somatic pain
- B. Visceral pain
- C. Ischemic pain
- D. Neuropathic pain
Correct Answer: A
Rationale: Throbbing and sharp pain describe somatic pain, arising from skin or musculoskeletal tissue. Visceral pain is dull, ischemic pain is aching, and neuropathic pain is burning or tingling.
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The nurse is developing a plan of care for a client with pertussis. It would be appropriate for the nurse to include which interventions? Select all that apply.
- A. Wear a surgical mask when working within three feet of the client
- B. Provide disposable dishes for meals
- C. Keep the client's room door closed
- D. Provide the client with a portable fan
- E. Maintain negative air pressure
- F. Apply a N95 mask to the client during transport
- G. Place the client in a room near the nurse's station
Correct Answer: A,C,F
Rationale: Pertussis requires droplet precautions: surgical mask within 3 feet, closed door, and N95 for transport. Disposable dishes, fans, and negative pressure are not needed.
The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has
- A. decreased postoperative pain
- B. increased postoperative vital capacity
- C. less postoperative blood loss
- D. no surgical site infection
Correct Answer: C
Rationale: Tranexamic acid is an antifibrinolytic that reduces bleeding by inhibiting clot breakdown. Its therapeutic effect is evident with less postoperative blood loss. It does not directly affect pain, vital capacity, or infection rates.
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 plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is assessing a client who had gastric bypass surgery two days ago. The nurse should prioritize assessing the client for
- A. venous thromboembolism
- B. their current weight
- C. nausea and vomiting
- D. surgical site infection
Correct Answer: C
Rationale: Nausea and vomiting are priority assessments post-gastric bypass due to the risk of anastomotic leaks or obstruction, which can be life-threatening. Venous thromboembolism and surgical site infection are concerns but less immediate, and weight assessment is not a priority at this stage.