Nokea
The nurse is providing preoperative teaching to a client scheduled for a pneumonectomy. Which of the following statements should the nurse make to the client?
- A. You must lay on your nonoperative side immediately following this surgery
- B. You can expect your lung function to return to normal within two to six hours
- C. You will want to avoid coughing after this surgery as you will be suctioned using a catheter
- D. You will be encouraged to get up and walk the same day as your surgery
Correct Answer: D
Rationale: Early ambulation post-pneumonectomy promotes lung expansion, prevents complications like pneumonia, and aids recovery. Lying on the nonoperative side is not universally required, lung function does not return to normal in hours, and coughing is encouraged to clear secretions, not avoided.
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The nurse is assisting a client with the use of a fracture bedpan. Which action should the nurse take?
- A. Position the client prone while placing the bedpan.
- B. Raise the head of the bed to 30 degrees.
- C. Place the open rim of the bedpan toward the head of the bed.
- D. Lower all of the side rails
Correct Answer: B
Rationale: Raising the head of the bed to 30 degrees facilitates client comfort and proper positioning for a fracture bedpan. Prone positioning is incorrect, the open rim faces the foot of the bed, and lowering all side rails is unsafe.
A health care provider (HCP) orders the immediate use of a piece of electrical care equipment for a client. When the nurse goes to use the piece of equipment, the nurse immediately suspects it may be faulty. The nurse should take which initial action?
- A. Try the piece of electrical care equipment and see if it becomes hazardous.
- B. Call the health care provider and report your suspicion.
- C. Ask the client if they want you to try the piece of electrical care equipment.
- D. Immediately remove the piece of electrical care equipment from service.
Correct Answer: D
Rationale: Removing faulty equipment from service prevents harm, the priority action. Trying it, consulting the client, or calling the provider delays safety measures.
The nurse is caring for a client immediately following hypophysectomy. The nurse should position the client
- A. Trendelenburg
- B. Side-lying
- C. high-Fowler's
- D. Reverse Trendelenburg
Correct Answer: C
Rationale: High-Fowler’s position (head elevated 30–45 degrees) is recommended post-hypophysectomy to reduce intracranial pressure and prevent cerebrospinal fluid leakage. Trendelenburg and reverse Trendelenburg could increase pressure or disrupt surgical site healing, and side-lying is less effective for this purpose.
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 teaching a group of unlicensed assistive personnel (UAPs) concepts of client identification. Which situation would require two client identifiers? Select all that apply.
- A. Providing a meal tray
- B. Changing bed linens
- C. Replacing a suction canister
- D. Obtaining vital signs
- E. Providing range of motion exercises
Correct Answer: C,D
Rationale: Two client identifiers are required for procedures that involve direct client intervention with potential for error, such as replacing a suction canister (invasive equipment) and obtaining vital signs (recorded in medical records). Providing a meal tray, changing bed linens, and range of motion exercises do not typically require two identifiers.