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The surgical floor receives a new postoperative client from the postanesthesia care unit. Assessment reveals that the client has a patent airway and stable vital signs. The nurse should next:
- A. Check the dressing for signs of bleeding.
- B. Empty any peri-incisional drains.
- C. Assess the client's pain level.
- D. Assess the client's bladder.
Correct Answer: C
Rationale: After confirming airway and vital signs, assessing pain level is the next priority, as uncontrolled pain can affect recovery and complicate other assessments or interventions.
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A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client's hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should:
- A. Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing.
- B. Start an additional 22G I.V. site because the packed blood cells must be given in a separate line.
- C. Attach the packed blood cells to the existing 22G I.V. of 5% dextrose using Y tubing.
- D. Start an additional I.V. access device with a 22G Intracath.
Correct Answer: A
Rationale: Packed red blood cells should be administered via a 19G I.V. with normal saline using Y tubing to prevent hemolysis, which can occur with dextrose solutions.
The nurse has an order to administer 2 oz of lactulose (Cephulac) to a client who has cirrhosis. How many milliliters of lactulose should the nurse administer?
Correct Answer: 60 mL
Rationale: 2 oz = 60 mL (1 oz = 30 mL). Thus, the nurse should administer 60 mL of lactulose.
The nurse should teach the client that signs of digoxin toxicity include which of the following?
- A. Rash over the chest and back.
- B. Increased appetite.
- C. Visual disturbances such as seeing yellow spots.
- D. Elevated blood pressure.
Correct Answer: C
Rationale: Visual disturbances, like seeing yellow spots (xanthopsia), are a hallmark of digoxin toxicity, requiring prompt reporting.
A client with renal calculi has a history of dehydration. The nurse should:
- A. Encourage 3 L of fluid daily.
- B. Limit fluid to 1 L daily.
- C. Administer IV fluids only.
- D. Restrict activity.
Correct Answer: A
Rationale: High fluid intake (3 L) prevents stone formation by diluting urine.
The nurse is developing the discharge teaching plan for a client after a lumbar laminectomy L4-5 who will be returning to work in 6 weeks. Which of the following actions should the nurse encourage the client to avoid?
- A. Placing one foot on a stepstool during prolonged standing.
- B. Sleeping on the back with support under the knees.
- C. Maintaining average body weight for height.
- D. Sitting whenever possible.
Correct Answer: D
Rationale: Prolonged sitting can stress the surgical site and delay healing post-laminectomy.