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The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Have the client sign the surgical and transfusion permits.
- B. Notify the healthcare provider of the client's medication history.
- C. Ensure that the potential for bleeding is explained to the client.
- D. Observe the heparin injections sites for signs of bruising.
Correct Answer: B
Rationale: Notifying the healthcare provider of the client's heparin use is crucial to ensure appropriate perioperative management and prevent excessive bleeding during surgery.
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The nurse is caring for a client in the post anesthesia care unit (PACU) who underwent a thoracotomy two hours ago. The nurse observes vital signs of a heart rate of 140 beats/minute, a respiratory rate of 26 breaths/minute, and a blood pressure of 140/90 mm Hg. Which intervention is most important for the nurse to implement?
- A. Administer IV fluid bolus as prescribed by the healthcare provider.
- B. Medicate for pain and monitor vital signs according to protocol.
- C. Encourage the client to splint the incision with a pillow to cough and deep breathe.
- D. Apply oxygen at 10 L/minute via non-rebreather mask and monitor pulse oximeter.
Correct Answer: B
Rationale: Medicating for pain and monitoring vital signs is the most important intervention, as the elevated vital signs are likely due to inadequate pain control following a thoracotomy, which can lead to increased sympathetic activity.
The nurse is teaching a client with glomerulonephritis about self care. Which dietary recommendation should the nurse encourage the client to follow?
- A. Restrict protein intake by limiting meats and other high protein foods.
- B. Increase intake of high fiber foods, such as bran cereal.
- C. Limit oral fluid intake to 500 mL/day.
- D. Increase intake of potassium rich foods such as bananas or cantaloupe.
Correct Answer: A
Rationale: Restricting protein intake is often recommended for glomerulonephritis to reduce kidney workload and decrease proteinuria, slowing kidney damage progression.
The nurse reviews discharge instructions with a client who has gastroesophageal reflux disease (GERD). Which instruction is most important for the nurse to emphasize?
- A. Avoid wearing tight fitting clothes.
- B. Minimize intake of spicy foods.
- C. Begin a smoking cessation program.
- D. Remain upright following meals.
Correct Answer: D
Rationale: Remaining upright following meals is essential to prevent gastric reflux by reducing pressure on the lower esophageal sphincter, minimizing reflux episodes.
A client is admitted to the medical unit during an exacerbation of systemic lupus erythematosus (SLE). It is most important for the nurse to report which assessment finding to the healthcare provider?
- A. Muscle atrophy.
- B. Low grade fever.
- C. Joint pain.
- D. Hematuria.
Correct Answer: D
Rationale: Hematuria can indicate lupus nephritis, a serious complication of SLE. Prompt reporting to the healthcare provider is crucial for appropriate management and prevention of further kidney damage.
A client who had colon surgery 3 days ago is anxious and requesting assistance to reposition. While the nurse is turning the client, the wound dehisces and eviscerates. The nurse moistens an available sterile dressing and places it over the wound. Which intervention should the nurse implement next?
- A. Auscultate the abdomen for bowel sound activity.
- B. Bring additional sterile dressing supplies to the room.
- C. Obtain a sample of the drainage to send to the laboratory.
- D. Prepare the client to return to the operating room.
Correct Answer: D
Rationale: Preparing the client to return to the operating room is the priority to address the dehisced and eviscerated wound and prevent further complications.