Nokea
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
- A. “Avoid drinking liquids until the gag reflex returns.”
- B. “Avoid eating milk products for 24 hours.”
- C. “Notify a nurse if you experience blood in your urine.”
- D. “Remain supine for the time specified by the physician.”
Correct Answer: D
Rationale: The correct answer is D: “Remain supine for the time specified by the physician.” After a subarachnoid block, the client must remain lying down to prevent complications like spinal headaches due to cerebrospinal fluid leakage. This position helps maintain adequate spinal fluid pressure. Choice A is incorrect as fluid intake is important postoperatively. Choice B is not relevant to a subarachnoid block. Choice C is important but not the most crucial instruction compared to maintaining the supine position.
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Which of the ff symptoms should a nurse assess in a client when implementing interventions for trauma to the upper airway?
- A. Pain when talking
- B. Increased nasal swelling
- C. Burning in the throat
- D. Presence of laryngospasm INFECTIONS OF THE LOWER RESPIRATORY AIRWAY
Correct Answer: D
Rationale: The correct answer is D: Presence of laryngospasm. Laryngospasm is a serious complication of trauma to the upper airway that can lead to airway obstruction. Assessing for laryngospasm is crucial to ensure the client's airway remains patent. Pain when talking (A) is more related to vocal cord injury, increased nasal swelling (B) is a symptom of nasal trauma, and burning in the throat (C) may indicate pharyngeal injury, but laryngospasm (D) directly affects airway patency in upper airway trauma cases.
During chemotherapy for lymphocytic leukemia, a client develops abdominal pain, fever, and “horse barn” smelling diarrhea. It would be most important for the nurse to advise the physician to order:
- A. Enzyme-linked immunosuppressant assay
- B. Stool for Clostridium difficile test
- C. Flat palate X-ray of the abdomen
- D. Electrolyte panel and hemogram
Correct Answer: B
Rationale: The correct answer is B: Stool for Clostridium difficile test. In this scenario, the client is experiencing symptoms suggestive of a possible Clostridium difficile infection, a common complication of chemotherapy. The test is crucial to confirm the presence of C. difficile toxins in the stool, which would guide appropriate treatment with antibiotics such as metronidazole or vancomycin.
A: Enzyme-linked immunosuppressant assay is not relevant in this context as it is used to measure levels of immunosuppressant drugs, not for diagnosing C. difficile infection.
C: Flat palate X-ray of the abdomen is unnecessary and would not provide information about the cause of the symptoms.
D: Electrolyte panel and hemogram are important for monitoring overall health status but do not directly address the specific issue of possible C. difficile infection.
Why does the nurse instruct the client to avoid Valsalva maneuvers?
- A. Clients BP will decrease momentarily
- B. Client may lose consciousness
- C. Client may suffer from a myocardial
- D. Clients BP will increase momentarily infarction
Correct Answer: B
Rationale: The correct answer is B because performing Valsalva maneuver can lead to a sudden drop in blood pressure, causing the client to lose consciousness. This occurs due to the increased intra-abdominal pressure leading to decreased venous return to the heart. Choices A, C, and D are incorrect as they do not accurately reflect the consequences of Valsalva maneuver. Option A stating that the client's blood pressure will decrease momentarily is incorrect as it actually increases initially. Option C suggesting that the client may suffer from a myocardial infarction is incorrect as Valsalva maneuver does not directly cause heart attacks. Option D implying that the client's blood pressure will increase momentarily is also incorrect as the immediate effect is a rise followed by a significant drop.
After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Rationale for Correct Answer (C):
1. Safety first: Patient safety is the top priority in healthcare. Vital signs provide crucial information about the patient's condition.
2. Accountability: The nurse is responsible for ensuring accurate vital sign documentation. Asking the NAP to record vital signs before medication administration ensures accountability.
3. Communication: Clear communication between healthcare team members is essential to provide quality care. Asking the NAP to record vital signs promotes effective communication.
Summary of Incorrect Choices:
A (abnormal vital signs): Administering medications without knowing the patient's vital signs, especially if abnormal, can be dangerous and potentially harmful.
B (review upon return): Delaying vital sign assessment until later can lead to missed opportunities for timely intervention if the patient's condition changes.
D (omit vital signs): Neglecting vital signs based on assumption risks overlooking potential issues that could impact patient care and outcomes.
A client who is scheduled for a parathyroidectomy is worried about having to wear a scarf around his neck after surgery. What nursing diagnosis should the nurse document in the care plan?
- A. Risk for impaired physical mobility due to surgery
- B. Ineffective denial related to poor coping mechanisms
- C. Disturbed body image related to the incision scar
- D. Risk of injury related to surgical outcomes
Correct Answer: C
Rationale: The correct answer is C: Disturbed body image related to the incision scar. This nursing diagnosis is appropriate as the client's concern about wearing a scarf post-surgery indicates a potential disturbance in body image due to the visible scar. The nurse should address the client's emotional response and offer support to help cope with the change in appearance.
A: Risk for impaired physical mobility due to surgery - This choice is not directly related to the client's worry about wearing a scarf and focuses more on physical limitations post-surgery.
B: Ineffective denial related to poor coping mechanisms - This choice does not address the specific body image concern expressed by the client.
D: Risk of injury related to surgical outcomes - This choice does not address the client's emotional response to the scar and focuses on physical safety risks instead.