Nokea
The nurse is caring for a client who is having a thoracentesis. Following the procedure, the nurse monitors for complications. The initial post-procedure monitoring plan should include what? Select all that apply.
- A. Level of alertness
- B. Lung sounds
- C. Oxygen saturation
- D. Respiratory pattern
- E. Temperature
- F. Urine output
Correct Answer: A,B,C,D
Rationale: Monitoring alertness, lung sounds, oxygen saturation, and respiratory pattern detects complications like pneumothorax or respiratory distress.
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The nurse is caring for a woman who is admitted for a hysterectomy. The woman does not speak English. No staff members speak the client's language. Which approach by the nurse would be most appropriate when communicating with the client about her care before and after the surgery?
- A. Ask the woman's 8-year-old daughter who speaks English to interpret.
- B. Draw pictures and gesture when speaking to the client.
- C. Speak very slowly when giving the client instructions.
- D. Request an interpreter from social services.
Correct Answer: D
Rationale: The nurse should request an interpreter from social services to ensure accurate communication. Using a child to interpret is inappropriate due to medical terminology and privacy concerns. Pictures, gestures, or slow speech in English are insufficient for surgical care discussions.
An adult who recently had an amputation has an above-the-knee prosthesis. Which nursing action will do the most to help the client adjust to the prosthesis?
- A. Adjust the prosthesis for the client.
- B. Offer the client a cane or a walker for ease of movement.
- C. Place an 'at risk for fall' sign on the client's door.
- D. Allow the client to manage his own care.
Correct Answer: D
Rationale: Allowing self-management fosters independence and confidence with the prosthesis, promoting adjustment.
The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.
Triazolam (Halcion) 0.25 mg is ordered for a client at bedtime. When the nurse goes to give the medication, the client asks the nurse to leave it at the bedside because she wants to finish reading a book. What is the best action for the nurse to take?
- A. Leave the medication at the bedside as requested
- B. Return in one hour and offer the medication again
- C. Tell the client to call when she is ready for the medication
- D. Explain to the client that this is the time medications are given and she should take it now
Correct Answer: B
Rationale: Returning in an hour ensures medication administration while respecting the client's request, adhering to safety protocols. Leaving medication or delaying indefinitely risks errors.
The nurse is caring for a client who has been in alcohol detoxification for one week. The client has slurred speech and is bumping into doorframes and walking unsteadily. What is the most appropriate initial action by the nurse?
- A. Assess for Wernicke-Korsakoff syndrome
- B. Ask for an order for blood alcohol level
- C. Request a neurology consult
- D. Administer a PRN dose of diazepam (Valium)
Correct Answer: A
Rationale: Slurred speech and unsteady gait post-detox may indicate Wernicke-Korsakoff syndrome, a thiamine deficiency complication, requiring urgent assessment.