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The nurse is conducting a postoperative assessment of a client on the first day after renal surgery. Which of the following findings would be most important for the nurse to report to the physician?
- A. Temperature, 99.8°F (37.7°C).
- B. Urine output, 20 mL/hour.
- C. Absence of bowel sounds.
- D. A 2€ x 2€ area of serosanguineous drainage on the flank dressing.
Correct Answer: B
Rationale: Urine output of 20 mL/hour is critically low, indicating potential renal compromise or obstruction, requiring immediate physician notification.
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Before surgery for a known aortic aneurysm, the client's pulse pressure begins to widen, suggesting increased aortic valvular insufficiency. If the branches of the aortic arch are involved, the nurse should assess the client for:
- A. Low blood pressure
- B. Anxiety
- C. Headache
- D. Disorientation
Correct Answer: D
Rationale: Widening pulse pressure and aortic arch involvement in an aortic aneurysm suggest possible dissection affecting cerebral perfusion (e.g., carotid artery involvement), leading to disorientation or neurologic changes. Low blood pressure, anxiety, and headache are less specific or unrelated.
A nurse is assessing a 42-year-old client who has been receiving chemotherapy. The client has a platelet count of 22,000 cells/mm³ and has petechiae on the lower extremities. The nurse should advise the client to:
- A. Increase the amount of iron in the client's diet.
- B. Apply lotion to the lower extremities.
- C. Elevate the legs.
- D. Consult the oncologist.
Correct Answer: D
Rationale: A platelet count of 22,000/mm³ with petechiae indicates severe thrombocytopenia, requiring urgent consultation with the oncologist for potential platelet transfusion or treatment adjustment.
A 42-year-old client with breast cancer is concerned that her husband is depressed by her diagnosis. Which of the following changes in her husband's behavior may confirm her fears?
- A. Increased decisiveness.
- B. Problem-focused coping style.
- C. Increase in social interactions.
- D. Disturbance in his sleep patterns.
Correct Answer: D
Rationale: Sleep disturbances are a common symptom of depression, suggesting the husband may be struggling emotionally with his wife's diagnosis.
The nurse uses a Doppler ultrasound device to assess the client's lower extremities. In addition, the nurse calculates the ankle-brachial index to estimate stenosis of the:
- A. Arteries
- B. Aorta
- C. Carotid
- D. Veins
Correct Answer: A
Rationale: The ankle-brachial index (ABI) measures the ratio of ankle to brachial systolic blood pressure to assess arterial stenosis in the lower extremities. A low ABI indicates arterial narrowing, typical in PVD. It does not assess the aorta, carotid, or veins.
The nurse is caring for a client with a hyphema. The nurse should plan to take which action?
- A. Shield the affected eye.
- B. Place the client supine.
- C. Apply a cold compress to the eye.
- D. Request a prescription for aspirin.
Correct Answer: A
Rationale: Shielding the affected eye protects it from further injury in hyphema (blood in the anterior chamber). Supine positioning may worsen bleeding, cold compresses are not standard, and aspirin increases bleeding risk.