Nokea
The nurse is caring for a client who underwent moderate sedation for a closed shoulder reduction. The nurse reviews the client’s clinical data. Which post-procedure data requires immediate followup?
- A. Blood Pressure
- B. Glasgow Coma Scale
- C. Respirations
- D. Temperature
Correct Answer: C
Rationale: Respiratory depression is a critical risk post-moderate sedation, so abnormal respirations require immediate follow-up. Blood pressure, Glasgow Coma Scale, and temperature are important but secondary unless specific abnormalities are noted.
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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 home health nurse is caring for a 67-year-old female client with progressive multiple sclerosis.
Item 5 of 6
Current Medications
Nurses' Notes
• cephalexin 500 mg p.o. every six hours for 10 days
• diazepam 5 mg p.o. daily PRN muscle spasm
• multivitamin 1 tablet daily
• ergocalciferol 10,000 international units p.o. Daily
Which of the following instructions should the nurse include when teaching the client how to ambulate with a walker? Select all that apply.
- A. The top of the walker should line up with your wrist crease.
- B. Lean over the walker to maintain good balance.
- C. When going up the stairs, advance the walker up onto the step first.
- D. When getting up from a chair, use the chair's armrests to push yourself up.
- E. Move the walker forward 2 to 4 inches with each step.
Correct Answer: A,D
Rationale: The walker should align with the wrist crease for proper height, and using chair armrests ensures safe standing. Leaning over the walker risks imbalance, and the walker follows the stronger leg on stairs.
The occupational health nurse is conducting an in-service on reducing back injuries in the workplace. It would be correct for the nurse to identify that the most common location of back injuries is in the
- A. Cervical spine.
- B. Lumbar spine.
- C. Thoracic spine.
- D. Pelvis.
Correct Answer: B
Rationale: The lumbar spine is the most common site for back injuries due to its weight-bearing role and flexibility. Other areas are less frequently injured.
The nurse is caring for a client who has soft-limb wrist restraints applied. The highest priority for the nurse is to
- A. Provide the client with opportunities to discuss their feelings.
- B. Document the neurovascular assessments.
- C. Assess the client's mood and affect.
- D. Offer nutrition and hydration.
Correct Answer: B
Rationale: Neurovascular assessments ensure circulation and safety, the highest priority with restraints. Other actions are important but secondary.
The nurse is inserting an indwelling urinary catheter in a male client. It would be appropriate for the nurse to inflate the catheter's balloon when
- A. Meeting resistance.
- B. As soon as urine is observed in the tubing.
- C. After advancing to the point of bifurcation.
- D. After fully advancing the length of the catheter.
Correct Answer: C
Rationale: The balloon should be inflated after advancing the catheter to the bifurcation (Y-connector), ensuring it is in the bladder. Inflating too early or fully advancing risks trauma or improper placement.