Nokea
The nurse is preparing a client scheduled for hip arthroplasty in two hours. The nurse has received a prescription for tranexamic acid. The nurse understands that this medication has had a therapeutic effect when the client has
- A. decreased postoperative pain
- B. increased postoperative vital capacity
- C. less postoperative blood loss
- D. no surgical site infection
Correct Answer: C
Rationale: Tranexamic acid is an antifibrinolytic that reduces bleeding by inhibiting clot breakdown. Its therapeutic effect is evident with less postoperative blood loss. It does not directly affect pain, vital capacity, or infection rates.
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The nurse is observing the surgical aseptic technique of a nursing student. Which observation by the nurse requires follow-up?
- A. Spills sterile water onto the sterile field
- B. Uses sterile gloves to handle sterile supplies on a sterile field
- C. Has sterile gauze placed into the sterile field
- D. Keeps the sterile field above their waist
Correct Answer: A
Rationale: Spilling sterile water contaminates the sterile field, requiring follow-up. Other actions are consistent with aseptic technique.
A client with a history of confusion has difficulty remembering recent events and becomes disoriented when away from home. Which statement would provide the best reality orientation for this client?
- A. Good morning. Do you remember where you are?
- B. Hello, my name is Susan Jones and I am your nurse for today.
- C. How are you today? Remember, you're in the hospital.
- D. Good morning. You're in the hospital. I am your nurse, Susan Jones.
Correct Answer: D
Rationale: A clear, concise statement of location and nurse identity provides effective reality orientation without challenging the client’s memory. Other options are less direct or confrontational.
The nurse is caring for a child immediately post-operative following a tonsillectomy. Which assessment finding requires immediate follow-up?
- A. Discomfort while speaking
- B. Frequent swallowing
- C. Drowsiness
- D. Pain with occasional coughing
Correct Answer: B
Rationale: Frequent swallowing in a post-tonsillectomy child may indicate bleeding in the throat, as the child swallows blood, requiring immediate follow-up to prevent hemorrhage. Discomfort, drowsiness, and pain with coughing are expected findings and less urgent.
The nurse plans care for a client immediately post-operative. The nurse should initially assess the client's
- A. respiratory status
- B. tolerance to by-mouth (PO) fluids
- C. pain level
- D. ability to move the extremities
Correct Answer: A
Rationale: Respiratory status is the priority assessment post-operatively to ensure airway patency and adequate oxygenation, following the ABCs (airway, breathing, circulation) of care. Pain, fluid tolerance, and extremity movement are important but secondary to ensuring respiratory stability.
The nurse is supervising a newly hired nurse preparing a client for a computed tomography (CT) scan of the brain with intravenous (IV) contrast. Which action by the newly hired nurse requires follow-up?
- A. Encouraging fluids when the client returns from the scan.
- B. Confirming that the consent form is signed.
- C. Raising the side rails of the client's stretcher during transport.
- D. Canceling the CT scan if the client reports a shellfish allergy.
Correct Answer: D
Rationale: Canceling the CT scan for a shellfish allergy is premature; further evaluation is needed. Encouraging fluids, confirming consent, and raising side rails are appropriate.