Nokea
The nurse is caring for a client who is still experiencing light sedation after undergoing an emergency colectomy for bowel obstruction. Which postoperative pain intervention should the nurse implement first?
- A. Provide the first medication prescribed for pain management.
- B. Review medical records to obtain pain tolerance expectations.
- C. Wait until the client is awake before providing pain management.
- D. Attempt to obtain a self-report of pain level from the client.
Correct Answer: A
Rationale: Providing the prescribed pain medication first prevents pain escalation in a sedated client, using behavioral indicators like vital signs to guide administration, as self-reporting may be unreliable.
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To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)
- A. Teach the client breathing exercises.
- B. Establish a regular bladder routine.
- C. Perform chest physiotherapy.
- D. Encourage use of incentive spirometer.
- E. Initiate passive range of motion exercises.
Correct Answer: A,C,D,E
Rationale: Breathing exercises, chest physiotherapy, incentive spirometer use, and passive range of motion exercises directly address respiratory function and mobility, reducing the risk of pulmonary complications in ALS by improving lung expansion, mobilizing secretions, and maintaining joint mobility.
The nurse calls the healthcare provider because a client diagnosed with an abdominal aortic aneurysm (AAA) is reporting of low back pain. Which additional information about the client would be important for the nurse to tell the healthcare provider?
- A. White blood cell count and pulse rate.
- B. Hematocrit and blood pressure.
- C. Calcium level and skin condition.
- D. Serum amylase and level of consciousness.
Correct Answer: B
Rationale: Hematocrit and blood pressure are critical for AAA, as low hematocrit may indicate rupture or bleeding, and high blood pressure can exacerbate the aneurysm, necessitating urgent reporting.
While caring for a client with full-thickness burns covering 40% of the body, the nurse observes purulent drainage from the wounds. Before reporting this finding to the health care provider, the nurse should evaluate which laboratory value?
- A. Platelet count.
- B. Serum albumin.
- C. Neutrophil count.
- D. Blood pH level.
Correct Answer: C
Rationale: Neutrophil count is a measure of the body's immune response to infection. Neutrophils are the most abundant type of white blood cells and are the first line of defense against bacterial infections. A high neutrophil count can indicate an acute infection, such as that suggested by purulent drainage from burn wounds.
While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
- A. Calculate gestation from last menstrual cycle.
- B. Continue with surgery as scheduled.
- C. Perform a bedside pregnancy test.
- D. Notify the surgical team to cancel the surgery.
Correct Answer: C
Rationale: Performing a bedside pregnancy test immediately confirms or rules out pregnancy, ensuring safe surgical planning, as abdominal surgery poses risks to a fetus.
A client admitted to the emergency department with an acute exacerbation of peptic ulcer disease is vomiting and describing epigastric pain and nausea. After obtaining vital sign measurements, which prescription should the nurse implement first?
- A. Insert a nasogastric tube (NGT) and attach to low intermittent suction.
- B. Give a prescribed analgesic for temperature above 101°F (38.3° C).
- C. Place an indwelling urinary catheter and attach a bedside drainage unit.
- D. Send the client to x-ray for a flat plate of the abdomen.
Correct Answer: A
Rationale: Inserting an NGT with low intermittent suction decompresses the stomach, removes gastric contents, and relieves vomiting and pain, addressing the acute symptoms of peptic ulcer exacerbation first.