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The nurse is caring for a client who had gastric bypass surgery yesterday. Which
intervention is most important for the nurse to implement during the first 24
postoperative hours?
a. Insert an indwelling urinary catheter
b. Monitor for the appearance of an incisional hernia
c. Instruct the client to eat small frequent meals
d. Measure hourly urinary output.
Measure hourly urinary output.
Rationale: a serious early complications of gastric bypass surgery is an anastomoses
leak, often resulting in death.
,When preparing to discharge a male client who has been hospitalized for an
adrenal crisis, the client expresses concern about having another crisis. He tells
the nurse that he wants to stay in the hospital a few more days. Which
intervention should the nurse implement?
a. Administer anti-anxiety medication prior to providing discharge instructions
b. Schedule an appointment for an out-patient psychosocial assessment.
c. Obtain a blood cortisol level after last dose of synthetic ACTH
d. Encourage the healthcare provider to delay the client's discharge.
Schedule an appointment for an out-patient psychosocial assessment.
Rationale: Emotional stress can precipitate another adrenal crisis and should be
monitored with periodic psychosocial assessments. A may be indicated but does not
address the problem after discharge. A blood cortisol level is to diagnosis not to monitor
the ongoing disease process. Canceling the discharge only delays the resolution of the
problem.
An adult female client tells the nurse that though she is afraid her abusive
boyfriend might one day kill her, she keeps hoping that he will change. What
action should the nurse take first?
a. Report the finding to the police department
b. Discuss treatment options for abusive partners
c. Determine the frequency and type of client's abuse
,d. Explore client's readiness to discuss the situation.
Explore client's readiness to discuss the situation
Rationale: By assessing the client's level of readiness to discuss her situation the nurse
can begin to stablish trust so that further action can be taken to protect her. The nurse
needs the client's permission to report the abuse to the police department, which may
be obtained after trust is established. B might be an option during the discussion it is
most important that the client has a safe refuge even if the abusive partner does not
commit seeking help.
In caring for a client with Cushing syndrome, which serum laboratory value is
most important for the nurse to monitor?
a. Lactate
b. Glucose
c. Hemoglobin
d. Creatinine
Glucose
Rationale: Cushing syndrome, caused by excess corticosteroids causes hyperglycemia
and the client's serum glucose level should be monitor for this side effect.
, Azithromycin is prescribed for an adolescent female who has lower lobe
pneumonia and recurrent chlamydia. What information is most important for the
nurse to provide to this client
a. Have partner screened for human immunodeficiency virus
b. Report a sudden onset arthralgia to the healthcare provider
c. Decrease intake of high-fat-foods, caffeine, and alcohol
d. Use two forms of contraception while taking this drug.
Use two forms of contraception while taking this drug.
Rationale: Antibiotic, especially broad-spectrum drugs, like azithromycin, decrease the
effectiveness of oral contraceptives and some spermicides, so the adolescent should be
encouraging to use at least two forms of contraception to prevent pregnancy
Following discharge teaching, a male client with duodenal ulcer tells the nurse
the he will drink plenty of dairy products, such as milk, to help coat and protect
his ulcer. What is the best follow-up action by the nurse?
a. Remind the client that it is also important to switch to decaffeinated coffee and
tea.
b. Suggest that the client also plan to eat frequent small meals to reduce
discomfort
c. Review with the client the need to avoid foods that are rich in milk and cream.