Nokea
The nurse notes a client's preoperative hemoglobin is 9.8 g/dL. What is the priority nursing action?
- A. Administer iron supplements as ordered.
- B. Notify the surgeon of the result.
- C. Encourage a high-protein diet.
- D. Document the finding and continue preparations.
Correct Answer: B
Rationale: A hemoglobin of 9.8 g/dL indicates anemia, which increases surgical risks. Notifying the surgeon ensures evaluation and possible intervention before proceeding.
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A client who had a serious head injury with increased intracranial pressure is to be discharged to a rehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client? The client will:
- A. Exhibit no further episodes of short-term memory loss.
- B. Be able to return to his construction job in 3 weeks.
- C. Actively participate in the rehabilitation process as appropriate.
- D. Re campaign to the end display pre-injury personality traits.
Correct Answer: C
Rationale: Active participation in rehabilitation is a realistic and appropriate outcome, promoting recovery tailored to the client's abilities. Eliminating memory loss, returning to a physically demanding job soon, or fully restoring pre-injury personality are unrealistic due to the severity of the injury.
A 29-year-old woman is concerned about her personal risk factors for malignant melanoma. She is upset because her 49-year-old sister was recently diagnosed with the disease. After gathering information about the client's history of sun exposure, the nurse's best response would be to explain that:
- A. Some melanomas have a familial component and she should seek medical advice.
- B. Her personal risk is low because most melanomas occur at age 60 or later.
- C. Her personal risk is low because melanoma does not have a familial component.
- D. She should not worry because she did not experience severe sunburn as a child.
Correct Answer: A
Rationale: Melanoma can have a familial component, and a family history increases personal risk. Seeking medical advice for screening and risk assessment is appropriate, especially given her sister's diagnosis.
A female client diagnosed with lung cancer is to have a left lower lobectomy. Which of the following increase the client's risk of developing postoperative pulmonary complications?
- A. Height is 5 feet, 7 inches and weight is 110 lb.
- B. The client tends to keep her real feelings to herself.
- C. 8.88 stimulates and can climb one flight of stairs without dyspnea.
- D. The client is 58 years of age.
Correct Answer: A
Rationale: Low body weight (5'7€, 110 lb) indicates malnutrition, increasing the risk of postoperative pulmonary complications due to weakened respiratory muscles. Emotional suppression, good exercise tolerance, and age 58 are less directly related.
The client attends two sessions with the dietitian to learn about diet modifications to minimize gastroesophageal reflux. The teaching would be considered successful if the client says that she will decrease her intake of which of the following foods?
- A. Fats.
- B. High-sodium foods.
- C. Carbohydrates.
- D. High-calcium foods.
Correct Answer: A
Rationale: Decreasing fat intake is key to managing GERD, as fatty foods relax the lower esophageal sphincter and delay gastric emptying, worsening reflux.
The nurse is caring for a client who is receiving prescribed aspirin. Which of the following findings would indicate the client is having an adverse effect?
- A. Polyuria
- B. Hypokalemia
- C. Venous thromboembolism
- D. Black, tarry stools
Correct Answer: D
Rationale: Black, tarry stools indicate gastrointestinal bleeding, a serious adverse effect of aspirin due to its antiplatelet and irritant properties.