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Patient Data

Exhibits

Click to highlight the findings that would indicate the client is progressing as expected.

The nurse assesses the client. The client reports he was able to sleep through the night. The client notes continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers. The client reports mild nausea and has no desire to eat breakfast. There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage. The left arm is warm to touch. The client's left shoulder and collarbone are symmetric.

The client reports he was able to sleep through the night

continued numbness in his left arm, along with a tingling sensation, and is not able to move his fingers

The client reports mild nausea and has no desire to eat breakfast

There is a 1.18 in (3 cm) by 1.97 in (5 cm) area of blood noted on the bandage

The left arm is warm to touch

The client's left shoulder and collarbone are symmetric.

Answer and Explanation

The Correct Answer is ["A","E","F"]

Rationale for Correct Choices:

The client reports he was able to sleep through the night: Adequate rest indicates improved comfort and effective pain management postoperatively.
The left arm is warm to touch: Warmth confirms adequate circulation and tissue perfusion following surgery.
The client's left shoulder and collarbone are symmetric: Symmetry suggests proper surgical alignment and absence of acute displacement or swelling.

Rationale for Incorrect Choices:

Continued numbness in the left arm, tingling, and inability to move fingers: These findings raise concern for possible neurovascular compromise or prolonged effects of the nerve block.
Mild nausea and lack of desire to eat breakfast: This can be a transient side effect of anesthesia or analgesics but requires monitoring for persistence.
A 3 cm × 5 cm area of blood noted on the bandage: Postoperative dressings should have minimal drainage, so this amount of blood warrants assessment for active bleeding or hematoma formation.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. Pasta with fish and an orange: This is the best option because fish provides high-quality protein in moderation, pasta is low in potassium and phosphorus, and an orange provides vitamin C. While oranges contain potassium, a single serving can usually fit within dietary allowances if monitored.

B. Canned ham and green beans: Canned ham is high in sodium and phosphorus additives, both of which are harmful in CKD as they worsen fluid retention and bone-mineral imbalance.

C. Steak and baked potato with butter and cheese topping: Steak is a high-protein food that can increase uremic toxins, and baked potatoes are very high in potassium. The cheese topping adds extra phosphorus, making this meal unsafe for CKD clients.

D. Chicken, yams, pinto beans and pecans: While chicken is acceptable protein, yams and pinto beans are high in potassium, and pecans add excess phosphorus. This combination would increase the risk of electrolyte imbalance in CKD.

A. Furosemide. B. Intravenous (IV) human albumin. C. Lactulose. D. Loperamide.

Correct Answer is C

Explanation

A. Furosemide: Furosemide is a diuretic used to reduce fluid overload in cirrhosis, especially in ascites. However, it does not address the elevated ammonia level or the client’s confusion, which are signs of hepatic encephalopathy requiring more specific treatment.

B. Intravenous (IV) human albumin: Albumin may be administered to maintain intravascular volume and reduce ascites, but it does not lower serum ammonia. It is supportive therapy, not the priority intervention for encephalopathy.

C. Lactulose: Lactulose is the treatment of choice because it decreases serum ammonia by promoting its excretion through the stool. It helps improve mental status in clients with hepatic encephalopathy and is the most important prescription in this scenario.

D. Loperamide: Loperamide reduces diarrhea by slowing bowel motility, but in this case, diarrhea is beneficial for eliminating ammonia with lactulose. Using loperamide could worsen encephalopathy by reducing ammonia clearance.

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Correct Answer is A

Explanation

Correct Answer is C

Explanation

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