Nokea
The nurse is preparing to administer an enema to a client. Prior to administering this medication, the nurse should position this client
- A. Trendelenburg's position.
- B. Semi-Fowler's position.
- C. Left lateral position.
- D. Right lateral with the head of the bed lowered.
Correct Answer: C
Rationale: The left lateral position allows the enema solution to flow into the sigmoid colon via gravity. Other positions are less effective or impractical.
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The nurse is participating in a committee reviewing strategies to reduce falls in older adults. Which of the following recommendations by the nurse would be appropriate to make?
- A. Increase the availability of bedside commodes
- B. Recommend the occupational therapist assess the client for mobility and safety
- C. Reduce environmental lighting, especially at night
- D. Remove grab bars from the bathrooms
Correct Answer: A,B
Rationale: Bedside commodes and occupational therapy assessments reduce fall risk by improving access and mobility. Reducing lighting and removing grab bars increase fall risk.
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• Nurses' Notes
0920: Client presents for a follow-up visit. Client reports increased difficulty with activities of daily living because of dyspnea. Reports pain and swelling in both lower extremities that increases with movement. "Washing my hair now takes me an hour instead of fifteen minutes." Transverse surgical incision was pink, approximated, and crusted—9 inches in length. Two Jackson-Pratt drains contained a total of 15 mL of serumlike drainage. Incisional pain reported at a '4' on the Numerical Rating Scale. Endorses increased incisional pain while coughing. The client reports full adherence to postoperative enoxaparin self-injections. She reports ejecting the air bubble prior to injection. Reports relief with prescribed oxycodone-acetaminophen but experiences generalized itching and drowsiness after.
• Medical History
• gastric bypass surgery performed two years ago
• dyslipidemia
• diabetes mellitus (type two)
• Vital Signs
• T 99.0°F (37.2°C); HR 90 beats/min; RR 18 breaths/min; BP 119/67 mm Hg; Pulse oximetry 96% on room air.
The nurse in the medical office is caring for a 41-year-old client who is 2-week postoperative abdominoplasty. Which of the following assessment findings require immediate follow-up? Select all that apply.
- A. wound assessment findings
- B. tolerance with activities of daily living
- C. pain in lower extremities
- D. enoxaparin self-injections
- E. pulse, respirations, and blood pressure
Correct Answer: B,C,D
Rationale: Tolerance with activities of daily living. The client reports increased difficulty with activities of daily living (ADLs) due to dyspnea, which could indicate a significant complication, such as pulmonary embolism (PE). Dyspnea, especially in the postoperative period, should always be investigated promptly, as it could be a sign of a PE, which is a life-threatening emergency. Immediate follow-up is necessary to rule out PE or other respiratory or circulatory issues. Pain in lower extremities. Pain and swelling in the lower extremities that increase with movement could suggest deep vein thrombosis (DVT). This complication is especially concerning in a postoperative patient on anticoagulation therapy (enoxaparin). DVT can lead to pulmonary embolism if the clot dislodges, which could cause dyspnea. This requires immediate follow-up to assess for DVT and initiate treatment if necessary. The client reports full adherence to postoperative enoxaparin self-injections and mentions ejecting the air bubble before injection. This is an incorrect technique; ejecting the air bubble can result in an underdose of the medication, potentially leading to ineffective anticoagulation. This can increase the risk of complications like DVT or VTE. Correct technique is crucial to ensure proper dosing. Immediate follow-up is required to educate the client about appropriate injection techniques (not ejecting the air bubble) to prevent these risks.Wound assessment findings. The transverse surgical incision is described as pink, approximated, and crusted, which are normal findings in the early postoperative period. These findings suggest no signs of infection or delayed wound healing. Therefore, no immediate follow-up is required for this finding.Incision pain level and characteristics. The client reports incisional pain at a level of 4 on the Numerical Rating Scale and increased pain when coughing. This level of pain is within a manageable range for a postoperative patient. The description of the pain as incisional and aggravated by coughing is consistent with expected postoperative discomfort. The pain level is manageable, and this is not a priority concern for immediate follow-up unless it becomes severe or is associated with other complications (e.g., infection or dehiscence).
The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
- A. Nasogastric tube (NGT)
- B. Bottle of sterile water
- C. Suction equipment
- D. Tracheostomy
Correct Answer: C
Rationale: Cheiloplasty is a surgical repair of a cleft lip, which can affect the infant’s ability to feed and maintain a clear airway. Suction equipment is essential at the bedside to clear secretions or blood from the oral cavity, preventing airway obstruction and ensuring airway patency. A nasogastric tube is not typically required unless feeding difficulties are severe. Sterile water is not a priority for immediate postoperative care, and a tracheostomy is not indicated for this procedure.
The nurse is performing an initial home health visit on a client who had a stroke one week ago with left-sided hemiparesis. Select the findings in the admission note that require follow-up.
- A. Affect was flat, and the client appeared withdrawn
- B. The client reported full adherence to their prescribed medications
- C. The client reported that they missed two physical therapy appointments.
- D. The client reported that they removed the cane's rubber tip because it left marks on their flooring.
- E. The client ambulated with the cane and held it in their right hand.
- F. The client advanced the cane 12-14 inches (30-36 cm) with each step
Correct Answer: A,C,D
Rationale: Flat affect, missed therapy, and removed rubber tip indicate depression, non-adherence, and safety risks, needing follow-up. Medication adherence, correct cane use, and proper advancement are appropriate.
The nurse is removing an indwelling urinary catheter
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Nurses Note
The removal of the client’s indwelling urinary catheter was attempted. Perineal hygiene was performed before the removal. The urine collection bag was emptied with 450 mL of clear, straw-colored urine. 2 mL of fluid was removed during the deflation of the balloon. Resistance was felt when the tubing was removed, and the client reported discomfort.
Drag words from the choices below to fill the blank in the following sentence. Prior to attempting to remove the catheter again, the nurse should--------------------------
- A. place a warm compress over the perineum
- B. cut the balloon inflation valve
- C. position the client at 45 degrees
- D. further deflate the catheter balloon
Correct Answer: D
Rationale: The amount of fluid removed from the balloon (this secures the catheter in place inside of the bladder) was inadequate. 10 mL of fluid is typically used to inflate the catheter balloon to keep it secure inside the bladder. The nurse should further deflate the catheter balloon by passively allowing the fluid to fill the syringe. The nurse may gently pull back on the syringe plunger if this does not work. By removing the residual volume, the nurse should then remove the catheter.
Cutting the balloon inflation valve would negate the closed system. Cutting the valve is not standard practice and should not be done. Positioning the client 45 degrees is not appropriate for discontinuing an indwelling urinary catheter. The correct approach for positioning a client to remove an indwelling catheter is having a male client supine and a female in the dorsal recumbent position.
Placing a warm compress over the perineum may give the client comfort, but this will not effectively troubleshoot the problem with the catheter. The issue is not with a bladder spasm, yet an indwelling urinary catheter that has not been entirely deflated.