The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?
An adult who is in Buck's traction, and scheduled for hip arthroplasty within the next 12 hours.
An older client who is receiving packed red blood cells on the third day postoperatively for colon resection.
An older client with continuous bladder irrigation who is 2 days postoperatively for bladder surgery.
An adult one day postoperative laparoscopic cholecystectomy requesting pain medication.
The Correct Answer is B
A) Incorrect- Hip arthroplasty is a scheduled procedure, and there is no immediate indication of a critical condition that requires urgent attention.
B) Correct- Postoperative hemorrhage is a serious complication, and an older client receiving packed red blood cells may be experiencing active bleeding. This situation requires immediate assessment and intervention.
C) Incorrect- While continuous bladder irrigation requires monitoring, it is not as urgent as a potential postoperative hemorrhage.
D) Incorrect- Pain management is important, but it is not as urgent as assessing a client who may be experiencing active bleeding.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E"]
Explanation
Choice A rationale: Misplacing car keys occasionally is a common occurrence and may not necessarily indicate Alzheimer's disease. It can happen to anyone, especially when distracted or in a hurry.
Choice B rationale: Difficulty performing familiar tasks, such as cooking a meal or driving to a familiar location, is an early warning sign of Alzheimer's disease. It indicates changes in cognitive function.
Choice C rationale: Losing sense of time, such as not knowing the date, day of the week, or season, can be an early indicator of Alzheimer's disease. It reflects impairments in temporal orientation.
Choice D rationale: Problems with performing basic calculations, such as managing finances or following a recipe, are early signs of Alzheimer's disease. It shows a decline in cognitive abilities related to numbers and problem-solving.
Choice E rationale: Becoming lost in a usually familiar environment, such as getting disoriented in one's own neighborhood, is a significant early warning sign of Alzheimer's disease. It suggests spatial and memory impairments.
Correct Answer is C
Explanation
Emphysema is a chronic obstructive pulmonary disease (COPD) characterized by the destruction of lung tissue and loss of elasticity in the alveoli. This leads to poor gas exchange, specifically the reduced ability of oxygen to enter the bloodstream and carbon dioxide to be eliminated from the body. Impaired gas exchange can result in hypoxemia and hypercapnia, leading to symptoms such as shortness of breath, fatigue, and decreased exercise tolerance.
While self-care deficit, activity intolerance, and ineffective airway clearance are all potential complications associated with emphysema, impaired gas exchange is the priority due to its direct impact on the client's oxygenation and overall respiratory function.
Addressing impaired gas exchange and optimizing oxygenation is essential to support the client's respiratory health and prevent further complications. Management strategies for impaired gas exchange may include administering supplemental oxygen, implementing respiratory treatments to improve lung function, and providing education on breathing techniques and energy conservation.
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