Nokea
Which of the following is most likely to cause the client to experience postoperative nausea and vomiting?
- A. Total hip replacement.
- B. Mitral valve repair.
- C. Abdominal hysterectomy.
- D. Mastectomy of the left breast.
Correct Answer: C
Rationale: Abdominal hysterectomy involves manipulation of the gastrointestinal tract, increasing the risk of postoperative nausea and vomiting due to vagal stimulation and slowed gastric motility.
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The nurse monitors a client with cirrhosis for the development of hepatic encephalopathy. Which of the following would be an indication that hepatic encephalopathy is developing?
- A. Decreased mental status.
- B. Elevated blood pressure.
- C. Decreased urine output.
- D. Labored respirations.
Correct Answer: A
Rationale: Hepatic encephalopathy causes decreased mental status (A) due to ammonia buildup. Elevated blood pressure (B), decreased urine output (C), and labored respirations (D) are not primary indicators.
The nurse is obtaining a blood sample for a PTT test ordered for a client who is taking heparin. It is 5 a.m. When drawing the blood, the nurse should do which of the following? Select all that apply.
- A. Awake the client
- B. Check the armband for client identification number and compare with the order
- C. Label the sample vial in front of the client
- D. Verify the room number with the room assignment
- E. Ask the client to state his/her name
Correct Answer: B,C,E
Rationale: Rationales: B) Checking the armband ensures correct client identification, critical for safety. C) Labeling the vial in front of the client prevents errors. E) Asking the client to state their name confirms identity. A) Awakening the client is unnecessary if asleep, as the draw can be done gently. D) Room number is unreliable for identification.
A client who has been diagnosed with renal calculi reports that the pain is intermittent and less colicky. Which of the following nursing actions is most important at this time?
- A. Report hematuria to the physician.
- B. Strain the urine carefully.
- C. Administer meperidine (Demerol) every 3 hours.
- D. Apply warm compresses to the flank area.
Correct Answer: B
Rationale: Straining urine is critical when pain becomes intermittent, indicating possible stone passage, to confirm stone expulsion and guide treatment.
A client post-hemodialysis reports dizziness. The nurse should:
- A. Check blood pressure.
- B. Administer fluids.
- C. Encourage eating.
- D. Increase dialysis time.
Correct Answer: A
Rationale: Dizziness may indicate hypotension, a common post-dialysis issue.
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
- A. A developing infection.
- B. Bleeding in the operative site.
- C. Joint dislocation.
- D. Glue seepage into soft tissue.
Correct Answer: C
Rationale: Sudden pain and inability to move suggest joint dislocation, a surgical emergency.