A client with cast on the forearm is complaining of skin irritation from the edges of a cast. The nurse observes that the skin edges are pink and irritated. The nurse plans to do which of the following as a corrective action?
a. shake a small amount of powder under the cast rim
b. petal the edges of the cast with tape
c. use hair dryer set on a cool high setting to soothe the irritation
d. Massage the skin at the rim of the cast
ANSWER: B
RATIONALE: The nurse should petal the edges of the cast with tape to minimize skin irritation. A hair dryer is used on a cool low setting if a non plaster cast becomes wet. Massaging the skin will not help. Powder should not be shaken under the cast, because it could clump, becomes moist, and cause skin breakdown.
A family member wishes to donate a blood for the upcoming surgery of the client and asks the nurse, “How will I know if our blood type will match?”. In formulating an appropriate response, the nurse incorporates that which test will be used to test compatibility?
a. direct coombs’
b. indirect coombs’
c. monocyte count
d. eosinophil count
ANSWER: B
RATIONALE: The indirect coombs’ test detects circulating antibodies against red blood cells and is the “screening” component to type and screen the client’s blood. This test is used in addition to ABO typing, which is normally done to determine blood type.
A nurse has conducted preoperative teaching for a client scheduled for endoscopic retrograde cholangiopancreatography (ERCP) procedure. The nurse determines that the client needs additional teaching if he states that:
a. An anesthetic through spray will be used
b. Medication will be given orally for sedation
c. It is important to lie still during the procedure
d. A signed informed consent is necessary
ANSWER: B
RATIONALE: The client needs to lie still for ERCP, which takes about an hour to perform. An informed consent must be signed. Intravenous sedation (NOT ORALLY) is given to relax the client. The anesthetic spray is used to help keep the client from gaggling as the endoscope is passed.
After surgery, the client asks a nurse what is the significance of deep breathing and coughing. In formulating a response the nurse incorporates the understanding that retained pulmonary secretion in a post operative client can lead to:
a. Pneumonia
b. pulmonary edema
c. carbon dioxide retention
d. fluid imbalance
ANSWER: A
RATIONALE: The most common post operative respiratory problems are atelectasis, pneumonia and pulmonary emboli. Pneumonia is inflammation of lung tissue that causes productive cough, dyspnea and crackles.
A nurse is performing tracheostomy care to the client and replaced the tracheostomy tube holder. The nurse ensures that the tube holder is not too tight by checking if:
a. the client nods that he or she feels comfortable
b. the tracheostomy does not move more than ½ inch when the client is coughing
c. two fingers can be slid comfortably under the holder
d. four fingers can be slid comfortably under the holder
ANSWER: C
RATIONALE: There should be enough room for two fingers to slide comfortably under the tracheostomy holder. This ensures that the holder is tight enough to present tracheostomy dislocation, while preventing excessive constriction around the neck.
A nurse is conducting a preoperative teaching with a client for radical neck dissection. Initially, the nurse would focus on which piece of information?
a. information given to the client by the surgeon
b. client’s coping behavior
c. post operative communication techniques
d. client’s support system
ANSWER: A
RATIONALE: The first step to client education is establishing what client already knows. This allow the nurse to not only connect any misinformation but also to determine the starting point for teaching and to implement the education of the client’s level.
A female client arrives at the emergency room and scheduled for emergency surgery because of perforated gastric ulcer. A narcotic analgesic was administered and the client was sedated and cannot sign the operative consent form. What appropriate nursing action should be taken in the care of this client?
a. obtain the consent form from family member and have the consent witnessed by two persons
b. have the hospital chaplain signed the consent form immediately
c. obtain court order for surgery
d. send the client to surgery without the consent form being signed.
ANSWER:A
RATIONALE: Every effort must be done to obtain permission from a responsible family member to perform surgery if the client is unable to sign the consent form. Telephone consent must be witnessed by two persons who hear the family oral consent. The two witnessed sign the consent noting that an oral consent was obtained.
A nurse is developing a plan of care to a postoperative client. The nurse assesses the client for the presence of Homan’s sign and determines that this sign is positive or which of the following is observed?
a. absent bowel sound
b. incisional pain
c. pain with dorsiflexion of the foot
d. crackles on auscultation of the lungs
ANSWER: C
RATIONALE: To elicit Homan’s sign, the nurse would dorsiflex the client’s foot and assesses the client for pain in the calf area. If pain is present, a positive Homan’s sign is present.
A nurse is formulating a plan of care for a client scheduled for surgery. On the day of the operation, the nurse would do which of the following activities in the nursing care plan for client?
a. have the client void immediately before surgery
b. avoid oral hygiene and rinsing with mouthwash
c. report immediately any slight increase in blood pressure or pulse
d. verify that the client has not eaten for the last 24 hour
ANSWER: A
RATIONALE: The nurse would assist the client to void immediately before surgery so that the bladder will be empty. Any trauma or accidental puncture to the bladder is avoided.
A physician ordered to transfuse a unit of packed RBC for an assigned client. In planning coverage for the client, the nurse just looked for another available nurse to check the blood to be transfused. Once the blood was double checked, how long will the assigned nurse stay with the client?
a. 15 minutes
b. 5 minutes
c. 30 minutes
d. 45 minutes
ANSWER: A
RATIONALE: The nurse must remain with the client for the first 15 minutes of transfusion which is the most frequent period of danger of transfusion reaction. This enables the nurse to detect reactions and intervene quickly.
