Nokea
While caring for a patient following an uvulopalatopharyngoplasty (UPPP), the nurse monitors the patient for which complications in the immediate postoperative period?
- A. Snoring and foul-smelling breath
- B. Infection and electrolyte imbalance
- C. Loss of voice and severe sore throat
- D. Airway obstruction and hemorrhage
Correct Answer: D
Rationale: The correct answer is D. Airway obstruction and hemorrhage are critical complications to monitor after UPPP. Snoring (A) may persist initially, infection (B) is less common, and voice loss (C) is rare.
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A client develops volume overload from an IV that has infused too rapidly. What assessment would the nurse expect to find?
- A. S3 heart sound.
- B. Thready pulse.
- C. Flattened neck veins.
- D. Hypoventilation.
Correct Answer: A
Rationale: An S3 heart sound indicates volume overload.
Sixty-five-year-old Dominic is being transferred into the postanesthesia care unit (PACU) from the OR. Once there, initial assessment will focus on
- A. Airway, breathing, circulation, and wound site.
- B. Intake, output, and intravenous access.
- C. Abdominal sounds, oxygen level, and level of consciousness.
- D. Pulse oximetry, pupil responses, and deep tendon reflexes.
Correct Answer: A
Rationale: ABCs are prioritized in the immediate postoperative period.
A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?
- A. Check the tubing connections for leaks.
- B. Check the suction control outlet on the wall.
- C. Clamp the chest tube.
- D. Continue to monitor the client's respiratory status.
Correct Answer: A
Rationale: The correct answer is A: Check the tubing connections for leaks.
1. Slow, steady bubbling in the suction control chamber indicates an air leak in the system.
2. Checking the tubing connections for leaks is the appropriate action to identify and fix the issue.
3. This helps maintain the integrity of the closed chest drainage system and prevent complications.
Other choices are incorrect:
B: Checking the suction control outlet on the wall is not necessary as the issue is likely within the tubing system.
C: Clamping the chest tube could lead to tension pneumothorax and is not recommended unless ordered by a physician.
D: Continuing to monitor the client's respiratory status does not address the underlying problem of the air leak.
A client in an emergency department has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?
- A. Raise the foot of the bed to a 90° angle
- B. Remove the dressing to inspect the wound
- C. Prepare to insert a central line
- D. Administer oxygen via nasal cannula
Correct Answer: D
Rationale: The correct answer is D: Administer oxygen via nasal cannula. In a client with a sucking chest wound, the priority is to ensure adequate oxygenation due to potential respiratory compromise. Administering oxygen via nasal cannula will help improve oxygenation and support the client's respiratory function. This action takes precedence over other interventions as hypoxia can lead to further deterioration.
A: Raising the foot of the bed to a 90° angle is not indicated in this situation as it does not address the immediate need for oxygenation.
B: Removing the dressing to inspect the wound can worsen the condition by disrupting any seals in place to prevent air from entering the chest cavity.
C: Preparing to insert a central line is not the priority in this situation as the client's respiratory status needs to be stabilized first.
Sue has a mild dermatitis rash and asks for advice. You respond by saying
- A. Wash the area with an antiseptic soap frequently to keep the area clean.
- B. Use an antifungal ointment.
- C. Use talcum powder to soothe the inflamed skin.
- D. Use a mild steroidal cream.
Correct Answer: D
Rationale: Steroidal creams reduce inflammation in dermatitis.