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While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
- A. Calculate gestation from last menstrual cycle.
- B. Continue with surgery as scheduled.
- C. Perform a bedside pregnancy test.
- D. Notify the surgical team to cancel the surgery.
Correct Answer: C
Rationale: Performing a bedside pregnancy test immediately confirms or rules out pregnancy, ensuring safe surgical planning, as abdominal surgery poses risks to a fetus.
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A client with obstructive sleep apnea (OSA) calls the clinic to report difficulty wearing the continuous positive air pressure (CPAP) mask because it is uncomfortable. The client asks the nurse for an alternative way to manage sleep apnea. Which recommendation should the nurse provide?
- A. Begin a weight loss program.
- B. Drink 1 to 2 glasses of wine at bedtime.
- C. Take sedatives prior to sleep.
- D. Sleep with the head of the bed flat.
Correct Answer: A
Rationale: Weight loss can reduce fat deposits around the neck and throat, improving airflow and decreasing the severity of OSA, making it an effective alternative or complementary strategy to CPAP.
A client taking antibiotics for three days to treat a Streptococcal throat infection returns to the clinic reporting a feel itchy rash across the chest and arms. The nurse auscultates pulmonary wheezing and an elevated heart rate. Which action should the nurse implement?
- A. Swab the throat for a rapid strep test.
- B. Provide a mask for the client to wear.
- C. Instruct client to stop taking the antibiotics.
- D. Apply a hypoallergenic cream to the rash.
Correct Answer: C
Rationale: Symptoms like rash, wheezing, and tachycardia suggest an allergic reaction to antibiotics, requiring immediate cessation to prevent progression to severe reactions like anaphylaxis.
On the third postoperative day, a client who has had a hip replacement surgery becomes anxious and diaphoretic, and begins to experience auditory hallucinations. The client denies having any pain. The client's vital signs are pulse rate is 125 beats/minute, respiratory rate is 36 breaths/minute, and blood pressure is 166/88 mmHg. Which nursing interventions should the nurse implement? (Select all that apply.)
- A. Reorient to day and time frequently.
- B. Apply soft wrist restraints bilaterally.
- C. Administer a PRN dose of lorazepam.
- D. Turn the television on for distraction.
- E. Present a calm, supportive demeanor.
Correct Answer: A,C,E
Rationale: Reorienting, administering lorazepam, and presenting a calm demeanor help manage postoperative delirium symptoms like hallucinations, ensuring patient safety and comfort.
A client is recovering from an episode of urinary tract calculi. During discharge teaching, the client asks about dietary restrictions. In discussing food intake, the nurse should include which type of fluid limitation?
- A. Overall fluid intake.
- B. Tea and hot chocolate.
- C. Low-sodium soups.
- D. Citrus fruit juices.
Correct Answer: B
Rationale: Limiting tea and hot chocolate reduces oxalate intake, which can contribute to calcium oxalate stone formation, a common type of urinary tract calculi.
A client who fractured the right femur from a fall at home is placed in skeletal traction while awaiting surgery. When the client tells the nurse the need to urinate, which intervention should the nurse implement?
- A. Log roll the client and place adult disposable briefs beneath the client.
- B. Maintain traction while the client uses a urinal.
- C. Release the traction so the client can use a bedpan.
- D. Insert an indwelling urinary catheter preoperatively.
Correct Answer: B
Rationale: Maintaining traction while using a urinal preserves fracture alignment and stabilization, allowing safe and comfortable urination without compromising the injury.