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When completing the Preoperative Checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?
- A. Administer the prescribed pre-anesthetic medication.
- B. Note this new allergy prominently at the front of the chart.
- C. Contact the scrub nurse in the operating room.
- D. Inform the nurse anesthetist.
Correct Answer: D
Rationale: A newly discovered allergy must be communicated to the nurse anesthetist first, as it may affect anesthesia choices and prevent allergic reactions during surgery.
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The nurse is planning a home visit for a client with hepatitis. In order to prevent transmission the nurse should focus teaching on:
- A. Proper food handling.
- B. Insulin syringe disposal.
- C. Alpha-interferon.
- D. Use of condoms.
Correct Answer: D
Rationale: Hepatitis B and C are transmitted via body fluids, so condom use (D) prevents sexual transmission. Food handling (A) is more relevant for hepatitis A. Syringe disposal (B) applies to needle-sharing risks, and alpha-interferon (C) is treatment, not prevention.
The nurse instructs the client on health maintenance activities to help control symptoms from her hiatal hernia. Which of the following statements would indicate that the client has understood the instructions?
- A. I'll avoid lying down after a meal.'
- B. I can still enjoy my potato chips and cola at bedtime.'
- C. I wish I didn't have to give up swimming.'
- D. If I wear a girdle, I'll have more support for my stomach.'
Correct Answer: A
Rationale: Avoiding lying down after meals prevents reflux, indicating the client understands hiatal hernia management. The other statements are incorrect or irrelevant.
A client with vasospastic disorder (Raynaud's phenomenon) is scheduled for sympathectomy. This surgery is performed:
- A. In the early stages of the disease to prevent further circulatory disturbances
- B. When the disease is controlled by medication
- C. When the client is unable to control stress-related vasospasm
- D. When all other treatment alternatives have failed
Correct Answer: D
Rationale: Sympathectomy, which severs sympathetic nerves to reduce vasospasm, is a last-resort treatment for Raynaud's when all other options (medications, lifestyle changes) fail. It is not performed early, when controlled, or solely for stress-related vasospasm.
A client with deep vein thrombosis (DVT) has an edematous right lower extremity. The client lies on her right side frequently. Rubor is noted on the lateral aspect of the right ankle. From the data collected, the appropriate nursing diagnosis for this client would be:
- A. Activity intolerance related to complaints of pain in lower right extremity
- B. Ineffective health maintenance related to lack of knowledge about DVT
- C. Pain related to edema
- D. Risk for impaired skin integrity
Correct Answer: D
Rationale: Edema, frequent lying on the right side, and rubor (redness) indicate pressure and poor circulation, increasing the risk for skin breakdown. Risk for impaired skin integrity is the most appropriate nursing diagnosis. Activity intolerance, ineffective health maintenance, and pain are less specific to the data.
The client is ready for discharge after surgery for a deviated septum. Which of the following discharge instructions would be appropriate?
- A. Avoid activities that elicit Valsalva's maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding Valsalva's maneuver (e.g., straining, heavy lifting) prevents increased pressure that could cause bleeding or disrupt the surgical site.