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Three hours ago a client was thrown from a car into a ditch, and he is now admitted to the emergency department in a stable condition with vital signs within normal limits, alert and oriented with good coloring and an open fracture of the right tibia. For which signs and symptoms should the nurse be especially alert?
- A. Infection
- B. Deformity
- C. Shock
- D. None of the above
Correct Answer: C
Rationale: An open fracture increases the risk of infection and deformity, but shock is a critical systemic complication that can develop rapidly due to blood loss or pain, requiring vigilant monitoring.
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Following a transsphenoidal hypophysectomy, the nurse should assess the client for:
- A. Cerebrospinal fluid (CSF) leak.
- B. Fluctuating blood glucose levels.
- C. Cushing's syndrome.
- D. Cardiac arrhythmias.
Correct Answer: A
Rationale: A CSF leak is a potential complication of transsphenoidal hypophysectomy due to the surgical approach through the sphenoid sinus, requiring careful monitoring.
The nurse anticipates that the client who has received epidural anesthesia is at decreased risk for a spinal headache because:
- A. A 17G needle is used.
- B. A subarachnoid injection is made.
- C. A noncutting needle is used.
- D. A faster onset occurs.
Correct Answer: C
Rationale: Epidural anesthesia uses a noncutting needle, reducing dural puncture risk and thus lowering the incidence of spinal headache compared to spinal anesthesia.
A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug?
- A. Increased urine output.
- B. Improved level of consciousness.
- C. Increased bowel movements.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: Lactulose promotes bowel movements (C) to excrete ammonia, a common adverse effect. Urine output (A) and consciousness (B) are not adverse effects. Nausea (D) is less common.
The nurse should caution sexually active female clients taking isoniazid (INH) that the drug has which of the following effects?
- A. Increases the risk of vaginal infection.
- B. Has mutagenic effects on ova.
- C. Decreases the effectiveness of hormonal contraceptives.
- D. Inhibits ovulation.
Correct Answer: C
Rationale: Isoniazid induces liver enzymes, potentially reducing the effectiveness of hormonal contraceptives. It does not increase vaginal infection risk, affect ova, or inhibit ovulation.
A client who had a total hip replacement 2 days ago has developed an infection with a fever. The nursing diagnosis of fluid volume deficit related to diaphoresis is made. Which of the following is the most appropriate outcome?
- A. The client drinks 2,000 mL of fluid per day.
- B. The client understands how to manage the incision.
- C. The client's bed linens are changed as needed.
- D. The client's skin remains cool throughout hospitalization.
Correct Answer: A
Rationale: Drinking 2,000 mL of fluid daily addresses fluid volume deficit due to diaphoresis.