Nokea
A client is scheduled for a traditional abdominal cholecystectomy.
Which of the following statements, if made by the nurse to the client the night before surgery, is MOST important?
- A. It is important for you to eat foods from every level of the food pyramid and avoid excessive fats in your diet.'
- B. Place the pillow against your abdomen, take three deep breaths, hold your breath, and then cough two or three times.'
- C. There will be a machine available to you after surgery for you to use to continuously receive pain medication.'
- D. You may come back from surgery with a tube in your nose that drains your gall bladder.'
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each implementation. Is it desired? (1) not most important initially, teaching should be done before discharge (2) correct-should be done every two hours to prevent respiratory complications, splinting prevents abdominal jarring (3) PCA pumps used postoperative but medication is administered intermittently (4) NG tube used to drain stomach, T-tube used to drain common bile duct
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The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following actions is the PRIORITY?
- A. Monitor the client for neck swelling.
- B. Administer pain medication as needed.
- C. Encourage the client to cough and deep breathe.
- D. Check the incision for drainage.
Correct Answer: A
Rationale: Monitoring for neck swelling is the priority to detect hematoma, a life-threatening complication post-thyroidectomy that can cause airway obstruction. Options B, C, and D are important but secondary: pain management, respiratory exercises, and incision checks follow airway safety.
A woman is in active labor with her first child when her membranes rupture. She voices a concern to the nurse that she is afraid of having a 'dry labor.' Which of the following responses by the nurse would be MOST appropriate?
- A. The amniotic fluid provides only minimal lubrication for the labor process.
- B. The amniotic sac may impede the progress of labor and is often ruptured artificially.
- C. Labor is only slightly more difficult with early rupture of the amniotic sac.
- D. Because there is limited amniotic fluid, additional fluids will be supplied.
Correct Answer: B
Rationale: Rupture of membranes can facilitate labor by removing the sac, which may impede progress, addressing the client’s 'dry labor' concern. Options A, C, and D are incorrect: amniotic fluid has multiple roles, labor difficulty is not significantly increased, and no fluids are added.
Several days after a client had a myocardial infarction, the physician placed him on a 2-gm sodium diet.
Which of the following selections would indicate to the nurse an understanding of the diet?
- A. Scrambled egg, orange slices, and milk.
- B. Instant oatmeal, toast, and orange juice.
- C. Poached egg, bacon, and milk.
- D. Biscuit, fruit cup, and sausage.
Correct Answer: A
Rationale: Strategy: Determine the foods that are allowed on a 2-gm sodium diet. (1) correct-all items are low in sodium; milk is allowed on a salt-restricted diet (2) instant oatmeal has sodium added (3) bacon is high in sodium (4) all baked breads are high in sodium, as is sausage
The nurse is caring for a client with Rheumatoid Arthritis. Which nursing diagnosis should receive priority in the plan of care?
- A. Risk for injury
- B. Self care deficit
- C. Alteration in comfort
- D. Alteration in mobility
Correct Answer: C
Rationale: Alteration in comfort. Relieving pain is the number one objective of this client's plan of care.
The nurse and a nursing assistant are preparing to move an elderly immobile client up in the bed using a sheet. The staff should be standing on opposite sides of the bed even with the client's:
- A. Hips
- B. Knees
- C. Shoulders
- D. Chest
Correct Answer: C
Rationale: Positioning at the shoulders aligns staff with the client's upper body, ensuring safe and effective movement.