Nokea
The nurse is preparing for a client to undergo a closed reduction of the shoulder with moderate (procedural) sedation. The nurse plans on obtaining which clinical data during the procedure?
- A. Blood pressure
- B. End-tidal carbon dioxide [ETCO2] level
- C. Respiratory rate
- D. Blood glucose
- E. Oxygen saturation
Correct Answer: A,B,C,E
Rationale: During moderate sedation, monitoring blood pressure, end-tidal CO2, respiratory rate, and oxygen saturation is essential to assess cardiovascular and respiratory status, ensuring patient safety. Blood glucose is not routinely monitored unless indicated by the patient’s condition.
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Health History
45-year-old female admitted for laparoscopic cholecystectomy. The client recently had a weight loss of ten kilograms through dieting, and cholelithiasis was subsequently discovered. The client is alert and oriented x 4. No known drug allergies. No surgical history. The client takes levothyroxine for hypothyroidism.
• Vital Signs
Oral temperature 97 F (36° C); Pulse 90 bpm; Respirations 18; BP 110/64 mm Hg; Oxygen saturation 96% on room air.
A nurse is caring for a client in a surgery center scheduled for laparoscopic cholecystectomy.Click to specify if the nursing intervention is completed during the preoperative, intraoperative, or postoperative phase. Each intervention may be completed in more than one phase. Each row must have at least one but may have more than one response option selected.
- A. Verify the client’s name and date of birth
- B. Verify the client’s nothing-by-mouth (NPO) status
- C. Administration of prophylactic antibiotic
- D. Obtaining laboratory work such as complete blood count, clotting studies, and pregnancy test
- E. Assessment of the surgical incision site for type and amount drainage
- F. Verifying that the informed consent has been completed
- G. Confirming the correct sponge and instrument count
Correct Answer:
Rationale:
The nurse is caring for a client scheduled for surgery who is nothing by mouth (NPO) status. Which of the following prescription should the nurse clarify with the primary healthcare physician (PHCP)?
- A. Lispro insulin 5 units SubQ TID
- B. Glargine insulin 15 units SubQ QHS
- C. Vitamin B12 100 mcg IM Daily
- D. Clonidine patch transdermal TTS-1 0.1 mg/24 hours q 7 days
Correct Answer: A
Rationale: Lispro insulin is a rapid-acting insulin typically administered around mealtimes to manage postprandial glucose levels. Since the client is NPO, they are not eating, so administering lispro insulin could lead to hypoglycemia due to the absence of carbohydrate intake. The nurse should clarify this prescription with the PHCP to ensure safe management of the client’s blood glucose levels during the NPO period. Glargine insulin, a long-acting insulin, is appropriate for basal glucose control and does not require clarification. Vitamin B12 and clonidine are unrelated to food intake and safe for NPO status.
The nurse in the emergency department (ED) is caring for a child with erythema infectiosum (Fifth disease). Which transmission-based precautions should the nurse implement?
- A. Standard
- B. Droplet
- C. Contact
- D. Airborne
Correct Answer: A
Rationale: Erythema infectiosum is typically non-infectious once the rash appears, requiring only standard precautions.
Item 1 of 1 • Assessment
Neurological: Alert and Oriented x 4; anxious affect
Cardiovascular: S1, S2 heart tones; all peripheral pulses palpable; no edema
Gastrointestinal: Distended abdomen; absent bowel sounds; hiccups; reports persistent nausea
Genitourinary: Denies dysuria; voiding every 3-4 hours with straw-colored urine
Musculoskeletal: Full range of motion in all extremities; steady gait
Integumentary: Incision is approximated; moderate dry sanguineous drainage was noted on the dressing.
Pain: Reports incision pain as a 3 based on a scale of 0-10.
• Vital Signs
Blood Pressure 119/75 mm Hg
Temperature 99° F (37° C)
Heart rate 90/min
Respiratory rate 17 breaths per minute
Oxygen saturation 97% on room air
The nurse is caring for a client two days postoperative following a partial colectomy.Complete the sentence below from the list of options: The client is at risk of developing
--------------based on the client’s------------------------
- A. paralytic ileus
- B. wound infection
- C. intractable pain
- D. integumentary assessment
- E. pain assessment
- F. gastrointestinal assessment
Correct Answer: A,F
Rationale: The client exhibits signs of paralytic ileus, as evidenced by the gastrointestinal assessment findings (distended abdomen, absent bowel sounds, nausea, and hiccups).
The clinical data do not support wound infection as it is too early in the postoperative period for this to occur, and the client has no other manifestations supporting this finding.
Pain is expected in the postoperative period, and the current pain rating is mild-to-moderate (3). In contrast, intractable pain would be suggested by pain not relieved by medication and at a severe level.
The nurse is caring for a client who reports abdominal pain. When performing an abdominal assessment, the nurse should
- A. Auscultate for bowel sounds after inspecting the abdomen.
- B. Palpate the area where the client identifies pain prior to palpating other areas.
- C. Palpate to detect fluid, air, and fluid-filled or solid masses.
- D. Percuss for masses, tenderness, organ enlargement, and ascites.
Correct Answer: A
Rationale: Abdominal assessment follows the order: inspect, auscultate, percuss, palpate. Auscultation after inspection prevents altering bowel sounds. Palpating painful areas first or focusing only on palpation/percussion is incorrect.