Nokea
A postoperative appendectomy client who is complaining of incisional pain. A diabetic client who had a cardiac catheterization in the early AM. A postoperative cholecystectomy client who is complaining of incisional pain. A client with congestive heart failure who underwent diuresis in the hospital.
The nurse is planning discharge for a group of clients. It is MOST important to refer which of the following clients for home care?
- A. A postoperative appendectomy client who is complaining of incisional pain.
- B. A diabetic client who had a cardiac catheterization in the early AM.
- C. A postoperative cholecystectomy client who is complaining of incisional pain.
- D. A client with congestive heart failure who underwent diuresis in the hospital.
Correct Answer: D
Rationale: Strategy: Determine the least stable client. Remember the ABCs. (1) expected outcome, treat with analgesics (2) instruct no bending, straining, or lifting heavy objects for 24 hours, observe for bleeding, swelling, new bruising at puncture site (3) expected outcome, treat with analgesics (4) correct-assess for decreased circulating volume, hypotension, tachycardia, monitor for signs and symptoms of hypokalemia
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A client with bipolar disorder is reluctant to take lithium (Lithane) as prescribed. The most therapeutic response by the nurse to his refusal is
- A. You need to take your medicine, this is how you get well.
- B. If you refuse your medicine, we'll just have to give you a shot.
- C. What is it about the medicine that you don't like?
- D. I can see that you are uncomfortable right now, I'll wait until tomorrow.
Correct Answer: C
Rationale: What is it about the medicine that you don't like? This fosters trust and open communication, encouraging the client to express concerns.
While assessing a client in an outpatient facility with a panic disorder, the nurse completes a thorough health history and physical exam. Which finding is most significant for this client?
- A. Compulsive behavior
- B. Sense of impending doom
- C. Fear of flying
- D. Predictable episodes
Correct Answer: B
Rationale: Sense of impending doom. The feeling of overwhelming and uncontrollable doom is characteristic of a panic attack.
The nurse is caring for a client with a history of atrial fibrillation who is receiving amiodarone (Cordarone) 200 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue
- B. Dry cough and shortness of breath
- C. Occasional palpitations
- D. Mild nausea
Correct Answer: B
Rationale: Dry cough and shortness of breath suggest pulmonary toxicity, a serious amiodarone side effect. Options A, C, and D are less urgent: fatigue and nausea are common, and palpitations are expected in atrial fibrillation.
The nurse is assigned to a client who has heart failure. During the morning rounds the nurse sees the client develop sudden anxiety, diaphoresis and dyspnea. The nurse auscultates, crackles bilaterally. Which nursing intervention should be performed first?
- A. Take the client's vital signs
- B. Place the client in a sitting position with legs dangling
- C. Contact the health care provider
- D. Administer the PRN antianxiety agent
Correct Answer: B
Rationale: Place the client in a sitting position with legs dangling. This reduces venous return, alleviating pulmonary edema symptoms.
A client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible.
When the nurse assesses the incision of a client two days after surgery, a shiny, pink, open area is noted with the underlying bowel visible. Which of these actions should the nurse take FIRST?
- A. Cover the open area with sterile gauze soaked in normal saline.
- B. Reapply a sterile dressing after cleaning the incision with peroxide.
- C. Pack the opened area with sterile 3/4-inch gauze soaked in normal saline.
- D. Apply Neosporin ointment and cover the incision with Tegaderm dressing.
Correct Answer: A
Rationale: Strategy: All answers are implementation. Determine the outcome of each answer. Is it desired? (1) correct-evisceration is treated immediately by application of sterile gauze soaked in sterile normal saline, followed by notification of physician (2) not correct response to this complication (3) not correct response to this complication (4) not correct response to this complication