Nokea
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.
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Which of the following responses should the nurse avoid when communicating with a client who has just received a poor prognosis? Select all that apply.
- A. My mother has the same thing.
- B. I'll sit with you for a while.
- C. I think you should try having surgery.
- D. Don't cry, everything is going to be okay.
- E. Do you have any questions for me right now?
Correct Answer: A,C,D
Rationale: Avoid personal anecdotes, medical advice, or minimizing emotions, as they dismiss the client’s feelings. Offering presence and open-ended questions are therapeutic.
Following a detailed conversation between a nurse and a client regarding autologous blood donations, which of the following statements, if made by the client, would indicate the need for additional education on the topic?
- A. Autologous donations require a health care provider's (HCP) order
- B. There is no age limitation for autologous blood donations
- C. I can begin autologous blood donations five weeks before my surgery date and continue up until 72 hours before surgery
- D. My autologous blood donation will be screened for infectious diseases
Correct Answer: B
Rationale: There are age limitations for autologous blood donations, typically excluding very young or elderly patients due to health risks. The other statements are correct: a provider’s order is required, donations can start five weeks and stop 72 hours before surgery, and blood is screened for infectious diseases.
The nurse is counseling a client diagnosed with irritable bowel syndrome (IBS). The nurse should advise the client to increase their
- A. Dairy intake.
- B. Fiber intake.
- C. Fat intake.
- D. Calcium intake.
Correct Answer: B
Rationale: Fiber regulates bowel function in IBS. Dairy and fat may worsen symptoms, and calcium is unrelated to IBS management.
The nurse is caring for a post-operative client at high risk for pneumonia. Which intervention would be most effective in the prevention of this complication?
- A. Passive range of motion
- B. Sequential compression devices (SCDs)
- C. Early ambulation
- D. Prophylactic antibiotics
Correct Answer: C
Rationale: Early ambulation promotes lung expansion and secretion clearance, reducing pneumonia risk. Other options are less effective for this purpose.
A nurse is preparing a client's intravenous (IV) infusion. As the nurse was preparing to attach the distal end of the IV tubing to the client's needleless access device, the exposed tubing slipped and hit the top of the client's bedside table. Which of the following is the most appropriate action by the nurse?
- A. Replace the IV tubing with new tubing
- B. Discard the client's current needleless access device and replace it with a new one
- C. Wipe the distal end of the tubing with povidone-iodine to render it sterile
- D. Clean the needleless access device with an alcohol swab
Correct Answer: A
Rationale: Replacing the tubing ensures sterility after contact with a non-sterile surface.