Nokea
Which of the following activities should the nurse teach the client to implement after the removal of nasal packing on the second postoperative day?
- A. Avoid cleaning the nares until swelling has subsided.
- B. Apply water-soluble jelly to lubricate the nares.
- C. Keep a nasal drip pad in place to absorb secretions.
- D. Use a bulb syringe to gently irrigate nares.
Correct Answer: B
Rationale: Applying water-soluble jelly lubricates the nares, preventing crusting and discomfort post-packing removal. Cleaning is safe once packing is removed. A drip pad is unnecessary unless bleeding persists. Irrigation with a bulb syringe is not standard care.
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The nurse is preparing a continuing education course on blood transfusion reactions. The nurse recognizes which intervention would prevent an ABO incompatibility (hemolytic) transfusion error.
- A. Priming a Y-tubing blood administration set with 0.9% sodium chloride (normal saline).
- B. Ensure that the client has a patent 20-gauge peripheral vascular access device.
- C. Accurately label the client's blood specimen for crossmatching.
- D. Review the client's medication allergies.
Correct Answer: C
Rationale: Accurate labeling of the client’s blood specimen for crossmatching ensures the correct blood type is matched, preventing ABO incompatibility reactions. Priming with saline, ensuring IV access, and reviewing allergies do not directly prevent ABO mismatches.
A client is admitted to the hospital with a diagnosis of renal calculi. The client is experiencing severe flank pain and nausea; the temperature is 100.6°F (38.1°C). Which of the following would be a priority outcome for this client?
- A. Prevention of urinary tract complications.
- B. Alleviation of nausea.
- C. Alleviation of pain.
- D. Maintenance of fluid and electrolyte balance.
Correct Answer: C
Rationale: Severe flank pain is the most urgent issue, making pain alleviation the priority outcome to ensure client comfort and stability.
A client with renal calculi is prescribed tamsulosin. The nurse explains it:
- A. Dissolves stones.
- B. Relaxes ureter muscles.
- C. Reduces urine output.
- D. Prevents infection.
Correct Answer: B
Rationale: Tamsulosin relaxes ureter muscles, aiding stone passage.
A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client?
- A. Observing the client at regular intervals for opioid addiction.
- B. Encouraging the client to reduce analgesic use and tolerate the pain.
- C. Evaluating pain control at least every 2 hours.
- D. Increasing the amount of morphine if the client does not administer the medication.
Correct Answer: C
Rationale: Regularly evaluating pain control ensures adequate relief while monitoring for side effects, a priority in PCA management.
After surgery for an ileal conduit, the nurse should closely assess the client for the occurrence of which of the following complications related to pelvic surgery?
- A. Peritonitis.
- B. Thrombophlebitis.
- C. Ingestes.
- D. Inguinal hernia.
Correct Answer: A,B
Rationale: Peritonitis and thrombophlebitis are significant complications of pelvic surgery like an ileal conduit, due to potential infection or vascular issues. 'Ingestes' appears to be a typo and is not a recognized complication.