Nokea
When the nurse is conducting a preoperative interview with a client who is having a vaginal hysterectomy, the client states that she forgot to tell her doctor that she had a total hip replacement 3 years ago. The nurse communicates this information to the perioperative nurse because:
- A. The prosthesis may cause a problem with the electrosurgical unit used to control bleeding.
- B. The client should not have her hip externally rotated when she is positioned for the procedure.
- C. The perioperative nurse can inform the rest of the team about the total hip replacement.
- D. There is not enough time to notify the surgeon and note this finding on the history and physical information before the procedure.
Correct Answer: A
Rationale: A hip prosthesis can conduct electricity from an electrosurgical unit, risking burns or complications. Communicating this ensures precautions are taken during surgery.
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The nurse is caring for a 78-year-old male with lung cancer who is receiving chemotherapy. The client states he is not eating well but otherwise feels healthy. Which meal suggestion would be best for this client?
- A. Local health milk and strawberries.
- B. Toast, gelatin dessert, and cookies.
- C. Broiled chicken, green beans, and cottage cheese.
- D. Steak and french fries.
Correct Answer: C
Rationale: Broiled chicken, green beans, and cottage cheese provide high protein and nutrients with low fat, which is ideal for a client with poor appetite during chemotherapy to support nutrition without being heavy.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity based on lab and clinical findings (e.g., age, white blood cell count, glucose). Vital signs (B) and urine output (C) are important but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis.
The nurse provides discharge instructions to a client diagnosed with bacterial conjunctivitis. Which of the following statements by the client would indicate effective understanding? Select all that apply.
- A. It is okay for me to wear my contact lenses during this infection.'
- B. Swimming during this infection is allowed.'
- C. I should not share my towels with family members.'
- D. To prevent injury, I should not rub my eye.'
- E. I should wash my hands frequently.'
Correct Answer: C,D,E
Rationale: Bacterial conjunctivitis requires avoiding contact lenses and swimming to prevent worsening or spreading infection, not sharing towels, avoiding eye rubbing to prevent corneal damage, and frequent hand washing to reduce transmission.
A pulmonary artery catheter is inserted in a client with severe mitral stenosis and regurgitation. The nurse administers furosemide (Lasix) to treat pulmonary congestion and begins a Nitroprusside (Nipride) drip for afterload reduction per physician orders. The nurse notices a sudden drop in the pulmonary artery diastolic pressure and pulmonary artery wedge pressure. Which of the following has the highest priority?
- A. Assess the 12-lead EKG.
- B. Assess the blood pressure.
- C. Assess the lung sounds.
- D. Assess the urine output.
Correct Answer: B
Rationale: A sudden drop in pulmonary pressures may indicate hypotension from nitroprusside. Assessing blood pressure is the priority to ensure adequate perfusion.
A client is brought to the emergency department unconscious. An empty bottle of aspirin was found in his car, and a drug overdose is suspected. Which of the following medications should the nurse have available for further emergency treatment?
- A. Vitamin K.
- B. Dextrose 50%.
- C. Activated charcoal powder.
- D. Sodium thiosulfate.
Correct Answer: C
Rationale: Activated charcoal is used to adsorb aspirin in the stomach, reducing absorption in an overdose. Vitamin K is for anticoagulant reversal, dextrose for hypoglycemia, and sodium thiosulfate for cyanide poisoning.