Nokea
Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
- A. Empty and measure indwelling urinary catheter collection bags.
- B. Reposition clients for pain relief.
- C. Teach clients the proper use of the incentive spirometer.
- D. Tell the nurse if clients report they are having pain.
- E. Assess I.V. insertion site for redness.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (A), reposition clients (B), and report pain (D). Teaching (C) and assessing IV sites (E) require nursing judgment and are outside their scope.
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Which of the following statements would indicate to the nurse that the client who has undergone repair of her nasal septum has understood the discharge instructions?
- A. I should not shower until my packing is removed.
- B. I will take stool softeners and modify my diet to prevent constipation.
- C. Coughing every 2 hours is important to prevent respiratory complications.
- D. It is important to blow my nose each day to remove the dried secretions.
Correct Answer: B
Rationale: Taking stool softeners and modifying the diet to prevent constipation avoids straining (Valsalva's maneuver), which could cause bleeding or complications post-nasal surgery.
When comparing the hematocrit levels of a postoperative client, the nurse notes that the hematocrit decreased from 36% to 34% on the third day even though the RBC count and hemoglobin value remained within 10 mg/dL and 11.9 g/dL, respectively. The nurse should:
- A. Check the dressing and drains for frank bleeding.
- B. Call the physician.
- C. Continue to monitor vital signs.
- D. Start oxygen at 2 L/minute per nasal cannula.
Correct Answer: C
Rationale: A slight decrease in hematocrit (36% to 34%) on postoperative day 3, with stable RBC count and hemoglobin, is likely due to hemodilution from fluid administration rather than active bleeding. The nurse should continue to monitor vital signs and hematologic parameters. Checking for bleeding is unnecessary without signs of hemorrhage, calling the physician is premature, and oxygen is not indicated.
A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal flaring, and use of accessory muscles. The nurse should first:
- A. Administer bronchodilators as ordered.
- B. Initiate oxygen therapy as ordered.
- C. Start I.V. fluids as ordered.
- D. Teach the client diaphragmatic breathing.
Correct Answer: B
Rationale: In an acute asthma attack with severe dyspnea, initiating oxygen therapy corrects hypoxemia, a priority. Bronchodilators are critical but secondary to oxygenation. I.V. fluids and breathing techniques are supportive but not immediate priorities.
A client with type 1 diabetes mellitus is admitted to the emergency department. Which of the following respiratory patterns requires immediate action?
- A. Deep, rapid respirations with long expirations.
- B. Shallow respirations alternating with long expirations.
- C. Regular depth of respirations with frequent pauses.
- D. Short expirations and inspirations.
Correct Answer: A
Rationale: Deep, rapid respirations (Kussmaul respirations) indicate diabetic ketoacidosis, a life-threatening condition requiring immediate intervention.
The nurse advises the client who has had a femoral head prosthesis placement on the type of chair to sit in during the first 6 to 8 weeks after surgery. Which would be the correct type to recommend?
- A. A desk-type swivel chair.
- B. A padded upholstered chair.
- C. A high-backed chair with armrests.
- D. A recliner with an attached footrest.
Correct Answer: C
Rationale: A high-backed chair with armrests supports proper posture and safe transfers.