Nokea
Which symptom suggests a complication post-renal surgery?
- A. Urine output of 25 mL/hour.
- B. Temperature of 99°F.
- C. Mild incisional pain.
- D. Clear urine.
Correct Answer: A
Rationale: Low urine output (25 mL/hour) may indicate obstruction or renal impairment.
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When a client is receiving a cephalosporin, the nurse must monitor the client for which of the following?
- A. Drug-induced hemolytic anemia.
- B. Purpura.
- C. Infectious emboli.
- D. Ecchymosis.
Correct Answer: A
Rationale: Cephalosporins can rarely cause drug-induced hemolytic anemia by triggering an immune response that destroys red blood cells. The nurse should monitor for signs such as jaundice, dark urine, or a drop in hemoglobin. Purpura, infectious emboli, and ecchymosis are not commonly associated with cephalosporin use.
A client is admitted to the emergency department complaining of severe abdominal pain. A radiograph reveals a large abdominal aortic aneurysm. The primary goal at this time is to:
- A. Maintain circulation
- B. Manage pain
- C. Prepare the client for emergency surgery
- D. Teach postoperative breathing exercises
Correct Answer: C
Rationale: A large abdominal aortic aneurysm with severe pain suggests impending rupture, requiring emergency surgery to prevent catastrophic bleeding. Preparing the client for surgery is the primary goal, as it addresses the life-threatening condition. Circulation, pain, and breathing exercises are managed perioperatively.
Following a total hip replacement, the nurse should position the client in which of the following ways?
- A. Place weights alongside of the affected extremity to keep the extremity from rotating.
- B. Elevate both feet on two pillows.
- C. Keep the lower extremities adducted by use of an immobilization binder around both legs.
- D. Keep the extremity in slight abduction using an abduction splint or pillows placed between the thighs.
Correct Answer: D
Rationale: Slight abduction prevents dislocation by maintaining proper hip alignment.
The family cannot go with the surgical client past the doors that separate the public from the restricted area of the operating room suite. These traffic control measures are designed to:
- A. Protect the privacy of clients.
- B. Prevent electrical sparks that could ignite the anesthetic gases.
- C. Separate the family from the surgical team to prevent distraction of the client.
- D. Provide for an aseptic environment to prevent infection.
Correct Answer: D
Rationale: Restricting access to the operating room maintains an aseptic environment, reducing the risk of surgical site infections by limiting contamination.
The nurse identifies a medication error involving a client with a colostomy. Which action should the nurse take first?
- A. Administer the correct medication.
- B. Notify the physician and complete an incident report.
- C. Monitor the client for adverse effects.
- D. Educate the client about the error.
Correct Answer: B
Rationale: Notifying the physician and completing an incident report is the first action after a medication error to ensure proper follow-up and documentation. Administering medication, monitoring, or educating the client are secondary steps after reporting. CN: Safety and infection control; CL: Synthesize