Nokea
Which of the following items of documentation is not required for the nurse to have on the chart before the client is transported to the operating suite?
- A. Operative consent.
- B. History and physical information.
- C. Laboratory test results.
- D. Anesthesia note.
Correct Answer: D
Rationale: The anesthesia note is completed intraoperatively or post-procedure by the anesthesiologist. The other documents are required preoperatively to ensure informed consent and medical readiness.
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A client with type 1 diabetes mellitus has diabetic ketoacidosis. Which of the following findings has the greatest effect on fluid loss?
- A. Hypotension.
- B. Decreased serum potassium level.
- C. Rapid, deep respirations.
- D. Warm, dry skin.
Correct Answer: C
Rationale: Rapid, deep respirations (Kussmaul respirations) in diabetic ketoacidosis are a compensatory mechanism for acidosis, leading to significant fluid loss through hyperventilation.
After a subtotal gastrectomy, care of the client's nasogastric (NG) tube and drainage system should include which of the following nursing interventions?
- A. Irrigate the tube with 30 mL of sterile water every hour, if needed.
- B. Reposition the tube if it is not draining well.
- C. Monitor the client for nausea, vomiting, and abdominal distention.
- D. Turn the machine to high suction if the drainage is sluggish on low suction.
Correct Answer: C
Rationale: Monitoring for nausea, vomiting, and abdominal distention is essential to detect complications such as obstruction or ileus. Routine irrigation, repositioning, or increasing suction without medical orders is unsafe.
The nurse provides discharge instructions to a client diagnosed with bacterial conjunctivitis. Which of the following statements by the client would indicate effective understanding? Select all that apply.
- A. It is okay for me to wear my contact lenses during this infection.'
- B. Swimming during this infection is allowed.'
- C. I should not share my towels with family members.'
- D. To prevent injury, I should not rub my eye.'
- E. I should wash my hands frequently.'
Correct Answer: C,D,E
Rationale: Bacterial conjunctivitis requires avoiding contact lenses and swimming to prevent worsening or spreading infection, not sharing towels, avoiding eye rubbing to prevent corneal damage, and frequent hand washing to reduce transmission.
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?
- A. 10 seconds.
- B. 15 seconds.
- C. 25 seconds.
- D. 30 seconds.
Correct Answer: B
Rationale: Suctioning for no more than 15 seconds prevents hypoxia and trauma to the airway. Longer durations risk oxygen deprivation.
What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.