Nokea
The nurse is caring for a client who is using a portable wound suction unit (see figure). Six hours following surgery, the drainage unit is full. The nurse should do which of the following?
- A. Remove the drain from the incision.
- B. Notify the surgeon
- C. Empty drainage.
- D. Record the amount in the unit as output onthe client’s chart.
Correct Answer: C
Rationale: Portable wound suction units can be emptied and drained. The nurse should compress the unit after emptying to create suction before reinserting the plug. It is normal for the suction unit to be full six hours after surgery, and the nurse does not need to notify the surgeon. The drainage unit should be emptied when full or every 8 hours. The drain in the incision should remain in place until the surgeon removes it. While all drainage should be noted as output on the chart, recording the amount without emptying the drainage unit is not accurate nor is it safe practice.
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A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. Which of the following discharge instructions would be appropriate for the client?
- A. Avoid activities that elicit the Valsalva maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding the Valsalva maneuver (e.g., straining) prevents increased pressure that could dislodge packing or cause bleeding. Aspirin increases bleeding risk. Tooth brushing is safe with care. Heat may increase swelling; cold is preferred.
A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium (Sodium Pentothal) because this drug causes:
- A. Bradycardia.
- B. Complete muscle relaxation.
- C. Hypotension.
- D. Tachypnea.
Correct Answer: C
Rationale: Thiopental can cause hypotension, which is particularly risky in clients with impaired cardiac function, as it may exacerbate cardiovascular instability during induction.
A client is scheduled for a renal ultrasound. The nurse explains that:
- A. Contrast dye is used.
- B. No preparation is needed.
- C. Fasting is required.
- D. A sedative is given.
Correct Answer: B
Rationale: Renal ultrasound is non-invasive and requires no special preparation.
The American Heart Association (AHA) guidelines urge greater availability of automated external defibrillators (AEDs) and people trained to use them. AEDs are used in cardiac arrest situations for:
- A. Early defibrillation in cases of atrial fibrillation.
- B. Cardiovascular placement.
- C. Early defibrillation in cases of ventricular fibrillation.
- D. None of the above
Correct Answer: C
Rationale: AEDs are used for early defibrillation in ventricular fibrillation or pulseless ventricular tachycardia, as these are shockable rhythms that can be corrected to restore cardiac function.
When developing a teaching plan for a client who is prescribed acetaminophen (Tylenol) for muscle pain, which information should the nurse expect to include? Select all that apply.
- A. The drug can be used if the person is allergic to aspirin.
- B. Acetaminophen does not affect platelet aggregation.
- C. This drug causes little or no gastric distress.
- D. Acetaminophen exerts a strong antiinflammatory effect.
- E. The client should have the International Normalized Ratio (INR) checked regularly.
Correct Answer: A,B,C
Rationale: Acetaminophen is safe for aspirin allergies, does not affect platelets, and causes minimal gastric distress. It has weak anti-inflammatory effects and does not require INR monitoring.