The nurse supervises care of clients on a postoperative surgical unit. Which finding requires an immediate intervention by the nurse?
1. The nursing
... [Show More] assistive personnel (NAP) obtains vital signs on a client who had a bowel resection 24 hours ago.
2. The NAP assists a client who had an above-the-knee amputation apply an elastic bandage to the residual limb.
3. The NAP assists a client who had a stroke 3 days ago with feeding.
4. The NAP assists a client who had a laparoscopic cholecystectomy 6 hours ago ambulate.
3. The NAP assists a client who had a stroke 3 days ago with feeding.
( client requires assessment and evaluation; may have problems with gag and swallow reflex)
In preparation for a total laryngectomy, the nurse teaches a client how to support his neck after surgery. Which of the following demonstrations by the client indicates to the nurse that teaching is successful?
1. The client raises the elbows and places the hands behind the neck.
2. The client places one hand on the forehead and the other hand on the back of the head.
3. The client covers the ears with both hands and presses firmly.
4. The client grasps the chin with one hand and places the other hand on the forehead.
1. The client raises the elbows and places the hands behind the neck.
The nurse is caring for an elderly client receiving parenteral nutrition (PN) due to malnutrition. Which observation, if made by the nurse, indicates that the client is improving?
1. The client gains 8 lbs in one week.
2. The client's edema decreases.
3. The client's hemoglobin increases.
4. The client's output is greater than the intake.
2. The client's edema decreases.
(edema is manifestation of malnutrition; decreased serum protein levels cause fluid to move into interstitial space)
1: indicates fluid retention
The healthcare provider has ordered a fenestrated tracheostomy tube to be capped. Which is the MOST important action for the nurse to take before the tracheostomy tube is plugged?
1. Administer 100% oxygen.
2. Deflate the cuff of the tracheostomy tube.
3. Suction the tracheostomy tube.
4. Administer humidified oxygen.
2. Deflate the cuff of the tracheostomy tube. (allows for an airway)
1: unnecessary in this situation; done before suctioning
The nurse cares for the client diagnosed with Parkinson's. The nurse notes that the client is ambulating with short, accelerating steps. Which action is the MOST appropriate for the nurse to take?
1. Offer the client a wheelchair.
2. Provide the client a walker.
3. Suggest that the client wear comfortably fitting shoes.
4. Teach the client to walk with a broad-based gait.
4. Teach the client to walk with a broad- based gait. (concentrate on walking erect with eyes on horizon) 2: client needs to alter method of walking
The nurse instructs a client on 100 mg losartan (Cozaar) and 25 mg hydrochlorothiazide (Hyzaar 100-25) tablets to be taken once daily. Which statement requires an intervention by the nurse?
1. "I will eat more fresh fruits while taking this medication."
2. "I should call my health care provider if I develop swelling of my lips."
3. "I can take this medication with or without food."
4. "I understand that I may develop a dry cough while taking this medication."
4. "I understand that I may develop a dry cough while taking this medication."
(outcome not expected; dry, nonproductive cough may occur with angiotensin-converting
enzyme inhibitors (ACE inhibitors), not ARBs) losartan-ARBS
A 50-year-old man scheduled for a vasectomy asks the nurse if he will be able to have sexual intercourse when he recovers from the surgery. Which statement, if made by the nurse, would be MOST accurate?
1. "My understanding is that each case is different after this procedure."
2. "There will be a short period of time during which you will be unable to sustain an erection."
3. "Most couples find that their sexual activity is more spontaneous after a vasectomy."
4. "This surgery should have no permanent effect on your sexual functioning."
4. "This surgery should have no permanent effect on your sexual functioning." vasectomy-sterilization for men
The nurse teaches the client with a spinal cord injury how to perform self- catheterization at home. Which statement, if made by the client, indicates that teaching has been successful?
1. "I will keep the catheter in a plastic bag."
2. "I will catheterize myself every 2 hours."
3. "I will wear sterile gloves."
4. "I will wash the perineum with alcohol prior to catheterizing myself."
1. "I will keep the catheter in a plastic bag."
(after use, catheter is soaked in solution of Betadine, bleach, or hydrogen peroxide, then dried and stored in a towel or bag; clean procedure in the home)
2: cath self q 6-8 hrs
4: wash with soap and water [Show Less]