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The nurse is planning to give preoperative instructions to a client who will be undergoing rhinoplasty. Which of the following instructions should be included:
- A. After surgery, nasal packing will be in place for 7 to 10 days.
- B. Normal saline nose drops will need to be administered preoperatively.
- C. The results of the surgery will be immediately obvious postoperatively.
- D. Aspirin-containing medications should not be taken for 2 weeks before surgery.
Correct Answer: D
Rationale: Aspirin can increase bleeding risk, so it should be avoided for 2 weeks before surgery. Nasal packing is typically removed within 1–3 days. Saline drops are not routinely required preoperatively. Surgical results may take weeks to months to be fully apparent due to swelling.
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A client informs the nurse that she is using an herbal therapy while receiving chemotherapy. Which of the following actions should the nurse take?
- A. Determine what substances the client is using and make sure that the physician is aware of all therapies the client is using.
- B. Guide the client in the decision-making process to select either Western or alternative medicine.
- C. Encourage the client to seek alternative modalities that do not require the ingestion of substances.
- D. Recommend that the client stop using the alternative medicines immediately.
Correct Answer: A
Rationale: Determining the herbal therapies used and informing the physician ensures safety, as some herbs can interact with chemotherapy drugs, affecting efficacy or toxicity.
A client is scheduled to have an arteriogram. During the arteriogram, the client reports having nausea, tingling, and dyspnea. The nurse's immediate action should be:
- A. Administer epinephrine
- B. Inform the physician
- C. Administer oxygen
- D. Inform the client that the procedure is almost over
Correct Answer: B
Rationale: Nausea, tingling, and dyspnea during an arteriogram suggest a possible allergic reaction to the contrast dye or other complications (e.g., vasovagal response). The nurse should immediately inform the physician to evaluate and manage the situation. Administering epinephrine or oxygen requires a physician's order, and reassuring the client is inappropriate until the issue is addressed.
The client with lymphedema has an increased risk of cellulitis and lymphangitis because of:
- A. Fragility of the capillaries.
- B. Myelosuppression of the bone marrow.
- C. Stagnation of accumulated fluid.
- D. Increased use of the extremity.
Correct Answer: C
Rationale: Stagnation of accumulated fluid in lymphedema creates an environment conducive to bacterial growth, increasing the risk of cellulitis and lymphangitis.
Which intervention is most appropriate for a client with impaired mobility due to a neurological condition?
- A. Encourage bed rest.
- B. Provide assistive devices.
- C. Limit physical therapy.
- D. Restrict fluid intake.
Correct Answer: B
Rationale: Providing assistive devices promotes safe mobility and independence for a client with impaired mobility.
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.