Nokea
Thrombus formation is a danger for all post operative patients. The nurse should act independently to prevent this complication by:
The nurse should act independently to prevent this complication by:
- A. Applying elastic stockings.
- B. Massaging gently with lotion.
- C. Encouraging in-bed exercises.
- D. Providing adequate fluids intake.
Correct Answer: C
Rationale: In-bed exercises promote venous return, reducing the risk of thrombus formation.
You may also like to solve these questions
A client with retinal detachment of the right eye has a scleral buckling with instillation of silicone oil. Post-operatively the client should be positioned:
- A. In semi-Fowler's position with the head in neutral position
- B. Supine with the head turned to the right side
- C. In low Trendelenburg position with the head in neutral position
- D. Prone with the head turned to the left side
Correct Answer: D
Rationale: Following a scleral buckling with instillation of silicone oil or gas, the client should be positioned prone with the head turned so that the operative eye is facing upward. Answers A, B, and C would displace the oil and prevent it from enhancing a seal between the retina and choroid.
The physician orders palifermin (Kepivance) 60 mcg/kg to be administered daily. The client weighs 35 kg. The medication is supplied 5 mg/mL. How many mL would you administer?
- A. 0.42 mL
- B. 30 mL
- C. 36.5 mL
- D. 33.6 mL
Correct Answer: A
Rationale: Dose: 60 mcg/kg × 35 kg = 2100 mcg = 2.1 mg. 2.1 mg ÷ 5 mg/mL = 0.42 mL. Other options are incorrect calculations.
The nurse is caring for a client with a fractured femur who is in skeletal traction. Which of the following actions is MOST important for the nurse to perform?
- A. Check the pin sites for signs of infection.
- B. Ensure the weights are hanging freely.
- C. Perform range-of-motion exercises on the affected leg.
- D. Reposition the client every 4 hours.
Correct Answer: B
Rationale: Ensuring weights hang freely maintains proper traction alignment, preventing complications like malunion. Checking pin sites (A) is important but secondary, ROM exercises (C) are contraindicated in traction, and repositioning (D) is limited to maintain traction.
John H is a 66-year-old man with a history of heavy smoking presented himself to the ER due to difficulty breathing of 2 years duration. Mr. H was also diagnosed with effusion of the right lung. He is now scheduled for chest tube insertion.
The level of the water in the water-seal chamber is at
- A. 2 cm
- B. -20 cm
- C. -10 cm
- D. -80 cm
Correct Answer: A
Rationale: The water-seal chamber is maintained at 2 cm to prevent air entry.
On the day of surgery, the nurse noted the following laboratory results.
Which one should be reported to the surgeon immediately?
- A. Creatinine level 1.7 mg/dl.
- B. WBC 12,000.
- C. Hemoglobin 12 mg/dl.
- D. Potassium level 5.0 mEq/L.
Correct Answer: B
Rationale: Elevated WBC is a sign of infection, which requires immediate reporting to the surgeon to assess the need to postpone surgery.