Nokea
Which nursing measure would be most effective in helping the client cough and deep breathe after a cholecystectomy?
- A. Having the client take rapid, shallow breaths to decrease pain.
- B. Having the client lay on the left side while coughing and deep breathing.
- C. Teaching the client to use a folded blanket or pillow to splint the incision.
- D. Withholding pain medication so the client can be alert enough to follow the nurse's instructions.
Correct Answer: C
Rationale: The correct answer is C: Teaching the client to use a folded blanket or pillow to splint the incision. This measure helps support the incision site, reducing pain during coughing and deep breathing. Splinting the incision promotes effective coughing and deep breathing post-surgery, aiding in lung expansion and preventing complications like atelectasis.
Explanation of why other choices are incorrect:
A: Having the client take rapid, shallow breaths to decrease pain is incorrect as it can lead to inadequate lung expansion and retention of secretions.
B: Having the client lay on the left side while coughing and deep breathing is incorrect as it does not directly support the incision site and may not be as effective in reducing pain.
D: Withholding pain medication so the client can be alert enough to follow the nurse's instructions is incorrect as pain management is crucial post-surgery for comfort and optimal recovery.
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A nurse is inserting a nasogastric tube in an adult client. During the procedure, the client begins to cough and has difficulty breathing. Which of the following is the most appropriate nursing action?
- A. Remove the tube and reinsert when the respiratory distress subsides.
- B. Pull back on the tube and wait until the respiratory distress subsides.
- C. Quickly insert the tube.
- D. Notify the physician immediately.
Correct Answer: B
Rationale: The correct answer is B: Pull back on the tube and wait until the respiratory distress subsides. This action allows for the nurse to relieve the pressure on the airway caused by the nasogastric tube, potentially alleviating the client's difficulty in breathing. It is important to prioritize the client's respiratory status and ensure they can breathe comfortably before proceeding with the procedure.
A: Removing the tube may worsen the respiratory distress and delay appropriate intervention.
C: Quickly inserting the tube can further compromise the client's breathing and cause more distress.
D: While notifying the physician is important, immediate intervention to address the breathing difficulty is crucial before seeking further assistance.
The nurse is caring for a client on the first postoperative day following a surgical repair of an abdominal aortic aneurysm. Which nursing diagnosis is the most important for this client?
- A. Risk for infection
- B. Deficient knowledge
- C. Ineffective peripheral tissue perfusion
- D. Activity intolerance
Correct Answer: C
Rationale: The correct answer is C: Ineffective peripheral tissue perfusion. This is the most important nursing diagnosis because after abdominal aortic aneurysm repair, there is a risk of compromised blood flow to peripheral tissues due to potential complications like embolism or thrombosis. Monitoring tissue perfusion is crucial to prevent complications such as tissue necrosis.
A: Risk for infection is important but not the priority immediately postoperatively.
B: Deficient knowledge may be addressed later once the client is stable.
D: Activity intolerance may be a concern but ensuring tissue perfusion is more critical in the immediate postoperative period.
In summary, monitoring and addressing ineffective peripheral tissue perfusion is essential for preventing serious complications following abdominal aortic aneurysm repair.
A Penrose drain is in place on the first postoperative day following a cholecystectomy. Serosanguineous drainage is noted on the dressing covering the drain. Which nursing intervention is most appropriate?
- A. Notify the physician.
- B. Change the dressing.
- C. Circle the amount on the dressing with a pen.
- D. Continue to monitor the drainage.
Correct Answer: B
Rationale: The correct answer is B: Change the dressing. This is the most appropriate intervention because serosanguineous drainage can indicate the need for a dressing change to prevent infection and ensure proper wound healing. Changing the dressing will also allow for better assessment of the drainage and the incision site.
A: Notifying the physician may not be necessary at this stage since serosanguineous drainage is expected in the early postoperative period.
C: Circling the amount on the dressing with a pen does not address the need for a dressing change or further assessment of the drainage.
D: Continuing to monitor the drainage is important, but changing the dressing is the immediate action needed to ensure proper wound care.
A client with viral hepatitis states, 'I am so yellow.' The nurse most appropriately would
- A. Assist the client in expressing feelings.
- B. Do most of the activities of daily living for the client.
- C. Provide information to the client only when the client requests it.
- D. Restrict visitors until the jaundice subsides.
Correct Answer: A
Rationale: The correct answer is A because assisting the client in expressing feelings shows empathy and addresses the client's emotional needs. It helps the client cope with the physical manifestations of the illness. Choice B is incorrect as it promotes dependence. Choice C is incorrect because providing information only upon request may not address the client's emotional distress. Choice D is incorrect as restricting visitors may further isolate the client.
A nurse is providing instructions to a client who will collect a stool specimen for occult blood. The nurse instructs the client to avoid which of the following for 3 days before the collection of the stool specimen?
- A. Milk products
- B. Hard cheese
- C. Turnips
- D. Cottage cheese
Correct Answer: C
Rationale: The correct answer is C: Turnips. Turnips contain peroxidase enzymes that can cause false-positive results in occult blood tests. Therefore, the client should avoid consuming turnips for 3 days before collecting the stool specimen.
Incorrect options:
A: Milk products - Milk products do not interfere with occult blood tests.
B: Hard cheese - Hard cheese does not contain peroxidase enzymes that would affect the test results.
D: Cottage cheese - Cottage cheese also does not contain peroxidase enzymes that would interfere with the test.