Nokea
Which problem would be appropriate for the nurse to identify for the preoperative client having an open reduction and internal fixation of the right ankle?
- A. Alteration in skin integrity.
- B. Knowledge deficit of postoperative care.
- C. Alteration in gas exchange and pattern.
- D. Alteration in urinary elimination.
Correct Answer: B
Rationale: Knowledge deficit of postoperative care (e.g., weight-bearing, wound care) is common pre-ankle surgery, guiding teaching. Skin integrity, gas exchange, and urinary issues are postoperative or unrelated.
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Which technique would be most appropriate for the nurse to implement when assessing a four (4)-year-old client in acute pain?
- A. Use words a four (4)-year-old child can remember.
- B. Explain the 0-to-10 pain scale to the child's parent.
- C. Have the child point to the face which describes the pain.
- D. Administer the medication every four (4) hours.
Correct Answer: C
Rationale: The FACES pain scale (pointing to faces) is age-appropriate for a 4-year-old, per pediatric pain assessment guidelines. Simple words are vague, numeric scales are for older children, and scheduled medication is not assessment.
The male client in the day surgery unit complains of difficulty urinating postoperatively. Which intervention should the nurse implement?
- A. Insert an indwelling catheter.
- B. Increase the intravenous fluid rate.
- C. Assist the client to stand to void.
- D. Encourage the client to increase fluids.
Correct Answer: C
Rationale: Standing to void facilitates urination by using gravity, a non-invasive first step. Catheterization, IV fluids, and oral fluids are more invasive or secondary.
Which client would the nurse identify as having the highest risk for developing postoperative complications?
- A. The 67-year-old client who is obese, has diabetes, and takes insulin.
- B. The 50-year-old client with arthritis taking nonsteroidal anti-inflammatory drugs.
- C. The 45-year-old client having abdominal surgery to remove the gallbladder.
- D. The 60-year-old client with anemia who smokes one (1) pack of cigarettes a day.
Correct Answer: A
Rationale: Obesity, diabetes, and insulin use increase risks for infection, poor wound healing, and glycemic instability, the highest risk profile. Arthritis, cholecystectomy, and anemia/smoking are less severe.
The unlicensed assistive personnel (UAP) reports the vital signs for a first-day postoperative client as T 100.8°F, P 80, R 24, and BP 148/80. Which intervention would be most appropriate for the nurse to implement?
- A. Administer the antibiotic earlier than scheduled.
- B. Change the dressing over the wound.
- C. Have the client turn, cough, and deep breathe every two (2) hours.
- D. Encourage the client to ambulate in the hall.
Correct Answer: C
Rationale: A low-grade fever (100.8°F) and tachypnea (R 24) suggest atelectasis; turning, coughing, and deep breathing prevent respiratory complications. Antibiotics, dressing changes, and ambulation are secondary.
The client in the surgical holding area tells the nurse 'I am so scared. I have never had surgery before.' Which statement would be the most appropriate response?
- A. Why are you afraid of the surgery?
- B. This is the best hospital in the city.
- C. Does having surgery make you afraid?
- D. There is no reason to be afraid.
Correct Answer: C
Rationale: Reflecting the client’s fear validates feelings, encouraging discussion. Asking 'why,' boasting about the hospital, or dismissing fear is less therapeutic.