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Questions 158

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Question 1 of 5

A client has returned to the unit following a left femoral popliteal bypass graft. Six hours later, his dorsalis pedis pulse cannot be palpated, and his foot is cool and dusky. The nurse should:

Correct Answer: B

Rationale: The physician should be notified immediately because the client is losing blood supply to his left foot and is in danger of losing the foot and/or leg.

Question 2 of 5

A client with obsessive compulsive personality disorder annoys his co-workers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:

Correct Answer: D

Rationale: Setting time schedules and deadlines helps manage the client's perfectionism and preoccupation with details, promoting efficiency without confrontation.

Question 3 of 5

A client with a history of peptic ulcer disease is admitted with complaints of hematemesis. The nurse should give priority to:

Correct Answer: B

Rationale: Hematemesis indicates possible gastrointestinal bleeding, so monitoring vital signs is critical to assess for hypovolemia and shock.

Question 4 of 5

A client undergoes a transurethral resection, prostate (TURP). He returns from surgery with a three-way continuous Foley irrigation of normal saline in progress. The purpose of this bladder irrigation is to prevent:

Correct Answer: B

Rationale: A three-way system of bladder irrigation will cleanse the bladder and prevent formation of blood clots. A catheter obstructed by clots or other debris will cause prostatic distention and hemorrhage.

Question 5 of 5

A client scheduled for disc surgery tells the nurse that she frequently uses the herbal supplement kava-kava (piper methysticum). The nurse should notify the doctor because kava-kava:

Correct Answer: A

Rationale: Kava-kava can potentiate the effects of anesthesia and analgesics, increasing the risk of excessive sedation or respiratory depression, necessitating physician awareness.

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