Nokea
Three hours following a right carotid endarterectomy, the nurse notes a moderate amount of bloody drainage on the client's dressing. Which additional assessment finding warrants immediate intervention by the nurse?
- A. Sore throat when swallowing
- B. Tongue deviation to the left
- C. Palpable temporal pulses
- D. Temperature of 99.2°F (37.3°C)
Correct Answer: B
Rationale: Tongue deviation to the left is the correct answer. It could indicate a complication such as nerve injury or hematoma, which requires immediate attention. A sore throat when swallowing may be expected postoperatively but does not indicate an immediate complication. Palpable temporal pulses are a normal finding and do not require immediate intervention. A temperature of 99.2°F (37.3°C) is slightly elevated but does not suggest a critical issue related to the surgery.
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The nurse assesses a client one hour after starting a transfusion of packed red blood cells and determines that there are no indications of a transfusion reaction. What instructions should the nurse provide the unlicensed assistive personnel (UAP) who is working with the nurse?
- A. Continue to measure the client's vital signs every thirty minutes until the transfusion is complete
- B. Since a reaction did not occur, the priority is to maintain client comfort during the transfusion
- C. Monitor the client carefully for the next three hours and report the onset of a reaction immediately
- D. Notify the nurse when the transfusion has finished, so further client assessment can be done
Correct Answer: A
Rationale: The correct instruction for the UAP is to continue measuring the client's vital signs every thirty minutes until the transfusion is complete. This is important because continuous monitoring of vital signs during the transfusion helps detect any delayed reactions promptly. Choice B is incorrect because maintaining client comfort is important but not the priority over monitoring vital signs. Choice C is incorrect as monitoring should be ongoing and not limited to a specific time frame. Choice D is incorrect as the UAP should monitor vital signs throughout the transfusion, not just at the end.
A client with a peripherally inserted central catheter (PICC) line has a fever. What client assessment is most important for the nurse to perform?
- A. Observe the PICC line site for inflammation.
- B. Encourage increasing fluid intake.
- C. Monitor blood pressure regularly.
- D. Assess skin turgor for dehydration.
Correct Answer: A
Rationale: The correct answer is to observe the PICC line site for inflammation. When a client with a PICC line develops a fever, it could indicate an infection related to the catheter. Assessing the PICC line site for signs of inflammation, such as redness, warmth, swelling, or drainage, is crucial in identifying a potential infection early. Choice B is incorrect because increasing fluid intake is not directly related to assessing a PICC line for infection. Choice C is not the most appropriate assessment in this situation as monitoring blood pressure may not directly help in identifying the cause of the fever. Choice D is unrelated to the assessment of a fever in a client with a PICC line.
The client who is to avoid any weight-bearing on the left leg is using a 3-point crutch gait for ambulation. What is the best action for the nurse to initiate?
- A. Encourage continued use of the 3-point crutch gait by the client
- B. Encourage the client to use a wheelchair for mobility
- C. Instruct the client in the use of a 4-point crutch gait
- D. Instruct the client in the use of a 2-point crutch gait
Correct Answer: C
Rationale: In this scenario, the client needs to avoid weight-bearing on the left leg. A 4-point crutch gait involves using both crutches and both legs, making it more appropriate for weight-bearing restrictions. Encouraging the use of a 3-point gait (choice A) would not provide adequate support for the client's condition. While using a wheelchair (choice B) could be an option, instructing the client in a 4-point crutch gait would promote mobility while adhering to weight-bearing restrictions. A 2-point crutch gait (choice D) involves using both crutches and one leg, which is not suitable for avoiding weight-bearing on the left leg.
Following an open reduction and internal fixation of a compound fracture of the leg, a male client complains of "a tingly sensation" in his left foot. The nurse determines the client's left pedal pulses are diminished. Based on these findings, what is the client's greatest risk?
- A. Reduce pulmonary ventilation and oxygenation related to fat embolism.
- B. Neurovascular and circulation compromise related to compartment syndrome.
- C. Wound infection and delayed healing due to fractured bone protrusion.
- D. Venous stasis and thrombophlebitis related to postoperative immobility.
Correct Answer: B
Rationale: The correct answer is B. Compartment syndrome is a serious condition that can occur following trauma or surgery, leading to compromised neurovascular status in the affected limb. Symptoms include pain, paresthesia (tingling sensation), and diminished pulses. If left untreated, compartment syndrome can result in tissue damage and potential loss of limb function. Options A, C, and D are incorrect because they do not directly address the neurovascular compromise associated with compartment syndrome.
The client is assessing a client who was recently diagnosed with heart failure and is on a low-sodium diet. Which statement by the client indicates a need for further teaching?
- A. "I will use lemon juice and herbs for flavoring."
- B. "I will not eat canned soups or frozen dinners."
- C. "I can have salt substitutes to enhance the taste of my food."
- D. "I will check the food labels for sodium content before buying."
Correct Answer: C
Rationale: The correct answer is C. Some salt substitutes can be high in potassium, which may not be suitable for clients with heart failure. Option A is correct as using lemon juice and herbs for flavoring is a good low-sodium alternative. Option B is also correct as canned soups and frozen dinners are typically high in sodium content. Option D is correct as checking food labels for sodium content is an essential part of managing a low-sodium diet. Therefore, the client's statement about using salt substitutes needs correction as it can introduce high levels of potassium, which may not be recommended for individuals with heart failure.