Nokea
The nurse is caring for a client who reports abdominal pain. When performing an abdominal assessment, the nurse should
- A. Auscultate for bowel sounds after inspecting the abdomen.
- B. Palpate the area where the client identifies pain prior to palpating other areas.
- C. Palpate to detect fluid, air, and fluid-filled or solid masses.
- D. Percuss for masses, tenderness, organ enlargement, and ascites.
Correct Answer: A
Rationale: Abdominal assessment follows the order: inspect, auscultate, percuss, palpate. Auscultation after inspection prevents altering bowel sounds. Palpating painful areas first or focusing only on palpation/percussion is incorrect.
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The emergency department charge nurse was notified of a mass shooting at a nearby shopping mall. The nurse should take which action to prepare for the surge in clients? Select all that apply.
- A. Work to arrange timely discharge and admission for appropriate clients.
- B. Establish a holding area for discharged clients not able to go home.
- C. Modify the nurse/client ratio to accommodate the surge levels.
- D. Instruct staff to switch from electronic to paper documentation.
- E. Prepare to provide frequent updates to local media.
Correct Answer: A,B
Rationale: Timely discharges/admissions and a holding area optimize resources. Modifying nurse ratios, switching to paper documentation, or media updates are not primary actions.
The nurse reviews a client’s laboratory data before a scheduled surgery. Which laboratory data requires immediate follow-up?
- A. Sodium level
- B. Potassium level
- C. Blood Urea Nitrogen (BUN)
- D. Creatinine
Correct Answer: B
Rationale: Abnormal potassium levels can cause cardiac arrhythmias, a critical risk during surgery, requiring immediate follow-up. Sodium, BUN, and creatinine abnormalities are less immediately life-threatening but still important.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
Health History
45-year-old female admitted for laparoscopic cholecystectomy. The client recently had a weight loss of ten kilograms through dieting, and cholelithiasis was subsequently discovered. The client is alert and oriented x 4. No known drug allergies. No surgical history. The client takes levothyroxine for hypothyroidism.
• Vital Signs
Oral temperature 97 F (36° C); Pulse 90 bpm; Respirations 18; BP 110/64 mm Hg; Oxygen saturation 96% on room air.
A nurse is caring for a client in a surgery center scheduled for laparoscopic cholecystectomy.Click to specify if the nursing intervention is completed during the preoperative, intraoperative, or postoperative phase. Each intervention may be completed in more than one phase. Each row must have at least one but may have more than one response option selected.
- A. Verify the client’s name and date of birth
- B. Verify the client’s nothing-by-mouth (NPO) status
- C. Administration of prophylactic antibiotic
- D. Obtaining laboratory work such as complete blood count, clotting studies, and pregnancy test
- E. Assessment of the surgical incision site for type and amount drainage
- F. Verifying that the informed consent has been completed
- G. Confirming the correct sponge and instrument count
Correct Answer:
Rationale:
The nurse is caring for an older adult receiving prescribed antibiotics for an infection. The client reports frequent watery stools that are foul-smelling. To prevent the spread of any potential secondary infection, the nurse should
- A. Place the client on contact (enteric) precautions.
- B. Place a surgical mask on the client during transport.
- C. Place face shields outside of the client's room.
- D. Keep the door to the client's room closed.
Correct Answer: A
Rationale: Foul-smelling, watery stools suggest possible Clostridium difficile, requiring contact (enteric) precautions to prevent spread. Masks, face shields, and closed doors are not specific to enteric infections.