Nokea
Which symptom indicates a potential complication in a client post-craniotomy?
- A. Mild headache.
- B. Clear nasal drainage.
- C. Stable blood pressure.
- D. Improved appetite.
Correct Answer: B
Rationale: Clear nasal drainage may indicate cerebrospinal fluid leakage, a serious post-craniotomy complication.
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A client with multiple sclerosis (MS) is experiencing bowel incontinence and is starting a bowel retraining program. Which strategy is inappropriate?
- A. Eating a diet high in fiber.
- B. Setting a regular time for elimination.
- C. Using an elevated toilet seat.
- D. Limiting fluid intake to 1,000 mL/day.
Correct Answer: D
Rationale: Limiting fluid intake to 1,000 mL/day is inappropriate, as adequate hydration is needed for bowel function. High-fiber diet, regular elimination times, and elevated toilet seats support bowel retraining.
After the administration of t-PA, the assessment priority is to:
- A. Monitor the client for chest pain.
- B. Monitor for fever.
- C. Monitor the 12-lead electrocardiogram (ECG) every 4 hours.
- D. Monitor breath sounds.
Correct Answer: A
Rationale: Monitoring for chest pain post-t-PA assesses for reperfusion success or reocclusion, a priority to ensure effective thrombolysis and myocardial perfusion.
The nurse is planning care for an 80-year-old client with a pressure ulcer (see figure). The nurse should do which of the following? Select all that apply
- A. Elevate the head of the bed to 50 degrees.
- B. Obtain daily cultures.
- C. Cover with protective dressing.
- D. Reposition the client every 2 hours
- E. Request an alternating-pressure mattress
Correct Answer: C,D,E
Rationale: The client has a Stage II pressure ulcer. The nurse should take measures to relieve the pressure, treat the local infection, and protect the wound. The nurse should keep the ulcer covered with a protective dressing.. The client should turn every 2 hours and use an alternating-pressure mattress to relieve pressure on the buttocks. The head of the bed should be elevated no more than 30 degrees. All wounds have bacteria and obtaining frequent cultures (unless ordered otherwise) are not necessary
Which of the following activities should the nurse encourage the unlicensed assistive personnel to assist with in the care of postoperative clients? Select all that apply.
- A. Empty and measure indwelling urinary catheter collection bags.
- B. Reposition clients for pain relief.
- C. Teach clients the proper use of the incentive spirometer.
- D. Tell the nurse if clients report they are having pain.
- E. Assess I.V. insertion site for redness.
Correct Answer: A,B,D
Rationale: Unlicensed assistive personnel can empty/measure catheter bags (A), reposition clients (B), and report pain (D). Teaching (C) and assessing IV sites (E) require nursing judgment and are outside their scope.
The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of:
- A. Atherosclerosis
- B. Diabetes
- C. Vasospastic disorder (Raynaud's disease)
- D. Thrombophlebitis
Correct Answer: D
Rationale: Obesity and estrogen-based oral contraceptives increase the risk of thrombophlebitis by promoting hypercoagulability and venous stasis, especially during surgery. Atherosclerosis, diabetes, and Raynaud's are less directly related to these risk factors.