The circulating nurse notes in the nutritional assessment of the client who is scheduled for total hip replacement surgery that the client is 20 lbs (9.07 kg) underweight for their height. The nurse should:

Weigh the patient prior to the procedure.

Use extra padding on bony prominences.

Use extra safety straps.

Notify the surgeon.

Answer and Explanation

The Correct Answer is D

Choice A reason: Weighing the patient prior to the procedure is a standard practice and ensures accurate dosing of medications and anesthesia. However, it does not address the immediate concern of the patient being underweight, which could impact their surgical and recovery outcomes.

Choice B reason: Using extra padding on bony prominences is important for preventing pressure ulcers, especially in underweight patients who have less natural padding. While this is a necessary precaution, it does not directly address the underlying issue of the patient’s nutritional status.

Choice C reason: Using extra safety straps can help secure the patient during surgery, but it does not address the nutritional concerns that could affect the patient’s recovery and overall health.

Choice D reason: Notifying the surgeon is crucial because the patient’s underweight status could significantly impact their surgical risk and recovery. The surgeon needs to be aware of this to make any necessary adjustments to the surgical plan or to involve a nutritionist or other specialists to address the patient’s nutritional needs before and after surgery.

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Correct Answer is B

Explanation

Maintaining adequate oxygenation is the primary goal for a client with impaired gas exchange due to an asthma exacerbation. Pulse oximetry is a non-invasive method to monitor the oxygen saturation of a patient’s blood, and values above 94% indicate sufficient oxygenation.

Choice A reason:

The client will demonstrate decreased episodes of coughing at night is important but not the priority goal. While reducing coughing can improve comfort and sleep quality, it does not directly address the critical issue of impaired gas exchange. The primary concern in an asthma exacerbation is ensuring that the client maintains adequate oxygen levels.

Choice B reason:

The client’s pulse oximetry values will remain above 94% on room air for the majority of the time is the priority goal. This goal directly addresses the issue of impaired gas exchange by ensuring that the client maintains adequate oxygenation. Pulse oximetry values above 94% indicate that the client’s blood is sufficiently oxygenated, which is crucial for preventing hypoxemia and ensuring that the body’s tissues receive enough oxygen to function properly.

Choice C reason:

The client’s breath sounds will only have slight wheezing by discharge is a relevant goal but not the priority. While reducing wheezing is an indicator of improved airway function, it is not as directly measurable or critical as maintaining adequate oxygen saturation. Wheezing can persist even when oxygen levels are adequate, so it is not the most reliable indicator of improved gas exchange.

Choice D reason:

The client will correctly demonstrate the use of a peak flow meter is an important educational goal but not the priority in an acute setting. Proper use of a peak flow meter can help the client monitor their asthma and prevent future exacerbations, but it does not directly address the immediate issue of impaired gas exchange. The priority in an acute asthma exacerbation is to ensure that the client is adequately oxygenated.

A. Apply an iodine-soaked sterile dressing. B. Irrigate the wound and apply a dry sterile dressing. C. Apply a dressing and notify the surgeon. D. Apply a sterile dressing soaked with normal saline.

Correct Answer is D

Explanation

Choice A Reason:

Applying an iodine-soaked sterile dressing is not the best initial action. Iodine can be irritating to exposed tissues and may not provide the necessary moisture to protect the underlying tissue. The primary goal is to keep the tissue moist and prevent further damage.

Choice B Reason:

Irrigating the wound and applying a dry sterile dressing is not appropriate in this situation. Irrigation might cause further damage to the exposed tissue, and a dry dressing will not keep the tissue moist, which is crucial for preventing desiccation and promoting healing.

Choice C Reason:

Applying a dressing and notifying the surgeon is important, but the type of dressing is crucial. A dry dressing or an inappropriate dressing material can harm the exposed tissue. The nurse should first apply a moist dressing to protect the tissue and then notify the surgeon.

Choice D Reason:

Applying a sterile dressing soaked with normal saline is the most appropriate initial action. This type of dressing keeps the exposed tissue moist, which is essential for preventing further damage and promoting healing. Normal saline is gentle and will not irritate the tissue, making it the best choice for initial wound care.

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The circulating nurse notes in the nutritional assessment of the client who is scheduled for total hip replacement surgery that the client is 20 lbs (9.07 kg) underweight for their height. The nurse should:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse prioritizes impaired gas exchange as a problem for a client with an asthma exacerbation. Which of the following is the client’s priority goal?

Correct Answer is B

Explanation

The nurse is changing a client’s abdominal dressing and notes a separation of the incision line. The underlying tissue is protruding from the wound. The nurse should plan to do which of the following in the initial care of this wound?

Correct Answer is D

Explanation

Which function or task during a surgical procedure is the responsibility of both the scrub and circulating nurses?

A client is diagnosed with asthma. The therapeutic regimen using metered dose inhalers includes albuterol 2 puffs and beclomethasone 2 puffs. The nursing plan of care must include teaching regarding:

The nurse is performing a physical assessment on the respiratory system. Although the client is currently confined to bed, they have the strength and ability to move and reposition themselves. The nurse instructs the client to assume which position for the assessment?

The nurse recognizes the assessment data which best indicates that the client diagnosed with asthma is achieving good control with the prescribed medication regimen is when:

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A nurse is assessing a newly admitted client whose chief complaint is “coughing up blood” and whose recent history includes a productive cough and night sweats. What is the nurse’s priority intervention?

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