Nokea
Which dietary instruction is most important for the nurse to explain to a client who has had gastric bypass surgery?
- A. Reduce intake of fatty foods.
- B. Chew slowly and thoroughly.
- C. Eat small frequent meals.
- D. Sip fluids with each meal.
Correct Answer: C
Rationale: Small, frequent meals prevent stomach pouch stretching and dumping syndrome, optimizing nutrient absorption.
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The nurse is caring for a client who reports a sudden, severe headache, and facial numbness. The nurse asks the client to smile and observes an uneven smile with facial droop to the right side and a hand grasp strength that is weaker on the right than the left. The client denies a recent history of headaches or trauma. Which intervention should the nurse perform in the immediate management of the client?
- A. Verify prescribed laboratory tests include prothrombin time and platelet count.
- B. Administer aspirin to prevent further clot formation and platelet clumping.
- C. Maintain elevated positioning of the dependent joints on affected side.
- D. Start two large bore IV catheters and review inclusion criteria for IV fibrinolytic therapy.
Correct Answer: D
Rationale: IV catheters and fibrinolytic criteria review are critical for potential thrombolytic therapy in suspected ischemic stroke.
A client with a fracture of the right femur has had skeletal traction applied. Which intervention should the nurse include in the client's nursing care plan?
- A. Administer pain medication at designated Intervals around the clock.
- B. Assess the pulses proximal to the fracture site.
- C. Remove traction every shift and provide skin care.
- D. Assess the pin sites for signs of infection.
Correct Answer: D
Rationale: Assessing pin sites for infection is critical in skeletal traction to prevent complications like osteomyelitis, which could delay healing.
The nurse is preparing a client for surgery who was admitted from the emergency department following a motor vehicle collision. The client has an open fracture of the femur and is bleeding moderately from the bone protrusion site. During the preoperative assessment, the nurse determines that the client currently receives heparin sodium 5,000 units SUBQ daily. Which nursing action is a priority?
- A. Notify the healthcare provider of the client's medication history.
- B. Have the client sign the surgical and transfusion permits.
- C. Observe the heparin injections sites for signs of bruising.
- D. Ensure that the potential for bleeding is explained to the client.
Correct Answer: A
Rationale: Notifying the provider about heparin use is critical to manage perioperative bleeding risk due to its anticoagulant effects.
Nurses' Notes
Physical Examination
Vital Signs
Day 1, 0830
Body mass index (BMI) is 31.8 kg/m2
Pain rating of 8 on 0 to 10 scale, in the right foot
Client history has been collected, and the nurse performs a physical assessment and records vital signs
Which finding(s) in the client's health record should the nurse recognize places the client at a greater risk of developing gout? Select all that apply.
- A. Drinks beer nightly
- B. Hypertension
- C. Sleep apnea
- D. Ibuprofen for pain
- E. Daily aspirin
- F. Type 2 diabetes mellitus
- G. osteoarthritis
Correct Answer: A,B,F,G
Rationale: Beer , hypertension , diabetes, osteoarthritis increase uric acid levels or metabolic risks for gout.
Which findings during the admission assessment should the nurse document that are related to a client diagnosed with Cushing's syndrome?
- A. Visible swelling of the neck, with no pain.
- B. Warm, soft, moist, salmon colored skin.
- C. Central type obesity, with thin extremities.
- D. Husky voice and troubled by hoarseness.
Correct Answer: C
Rationale: Central obesity with thin extremities is characteristic of Cushing's syndrome due to cortisol-induced fat redistribution.