Question

A nurse is caring for a client who is 24 hours post-operative following abdominal surgery. The client reports feeling lightheaded and dizzy when attempting to sit up. What is the nurse's priority action?

Answer 1

Correct Answers:

Assess the client's blood pressure and heart rate.

Rationale :

✅ Dizziness and lightheadedness with position change suggest possible orthostatic hypotension.

✅ A postoperative client may also be experiencing hypovolemia from fluid loss or bleeding.

✅ The nurse should assess blood pressure and heart rate first to determine whether the client is hemodynamically stable.

✅ A drop in blood pressure accompanied by tachycardia can indicate decreased circulating volume.

✅ Assessment should occur before treatment because the cause of the symptoms must be identified.

✅ The nurse should also assess for signs of postoperative bleeding, including pallor, diaphoresis, decreased urine output, wound drainage, or abdominal distention.

✅ After assessment, the nurse can determine whether interventions such as fluids, slow position changes, or provider notification are needed.

✅ Therefore, the priority action is to assess the client's blood pressure and heart rate.

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Answer 2

Correct Answers:

The new nurse left the client unattended.

Rationale :

🌼 A client who has received moderate sedation must be continuously monitored because sedation can depress respirations, protective reflexes, and level of consciousness.

🌼 The nurse should closely observe airway patency, respiratory rate, oxygen saturation, blood pressure, heart rate, and responsiveness.

🌼 Leaving the client unattended creates a serious safety risk because deterioration can occur rapidly.

🌼 Moderate sedation can cause hypoventilation, airway obstruction, hypotension, or excessive sedation.

🌼 Immediate intervention may be required if the client becomes difficult to arouse or develops respiratory compromise.

🌼 The nurse must remain with or ensure direct observation of the client until appropriate recovery criteria are met.

🌼 This makes unattended care the action that clearly requires correction by the circulating nurse.

🌼 Therefore, the new nurse should not leave the moderately sedated client unattended.

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Answer 3

Correct Answers:

To identify possible surgical risks

Rationale :

💠 The priority purpose of the preoperative assessment is to identify factors that could increase the client’s risk for complications during or after surgery.

💠 The nurse reviews the client’s medical history, allergies, medications, previous surgeries, and anesthesia history.

💠 Conditions such as cardiac disease, respiratory disorders, diabetes, renal impairment, bleeding disorders, and infection can significantly affect surgical outcomes.

💠 The nurse also assesses for medications that may increase risk, such as anticoagulants, antiplatelet drugs, corticosteroids, and certain herbal supplements.

💠 Baseline findings such as vital signs, laboratory values, hydration status, and nutritional status help identify abnormalities before surgery.

💠 Recognizing risks early allows the surgical team to take preventive measures and modify the plan of care if necessary.

💠 Preoperative risk identification supports patient safety and prevention of perioperative complications.

💠 Therefore, identifying possible surgical risks is the highest-priority goal of the preoperative assessment.

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Answer 4

Correct Answers:

Surgical excision

Rationale :

🌹 Surgical excision is the treatment of choice for localized malignant melanoma because the goal is to completely remove the tumor with an appropriate margin of normal tissue.

🌹 The width of the surgical margin depends largely on the Breslow thickness and other pathologic features of the melanoma.

🌹 Early-stage melanoma can often be treated effectively with wide local excision alone.

🌹 A sentinel lymph node biopsy may also be considered for certain melanomas based on tumor depth and other risk features.

🌹 Surgery provides definitive local control and allows the tissue to be examined for margin status and pathologic staging.

🌹 Chemotherapy and radiation are not the usual first-line treatment for a small, superficial, resectable melanoma.

🌹 More advanced melanoma may require immunotherapy or targeted therapy, depending on stage and tumor mutations.

🌹 Therefore, for a superficial malignant melanoma, the preferred initial treatment is surgical excision.

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Answer 5

Correct Answers:

0.5

Rationale :

💊 Formula:

Desired dose ÷ Dose on hand = Number of tablets

💊 Convert 0.5 g to mg:

0.5 g × 1,000 = 500 mg

💊 Substitute:

250 mg ÷ 500 mg = 0.5 tablet

✅ Final Answer: 0.5 tablet

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Answer 6

Correct Answers:

Notify the anesthesiologist and the surgeon.

Rationale :

✅ Failure to follow preoperative fasting guidelines increases the risk of pulmonary aspiration during anesthesia.

✅ General anesthesia and sedation can reduce protective airway reflexes, allowing stomach contents to enter the lungs.

✅ Aspiration can lead to serious complications such as chemical pneumonitis, airway obstruction, hypoxemia, or pneumonia.

✅ The nurse should immediately report the fasting violation to the anesthesiologist and surgeon, who will determine whether the procedure should proceed, be delayed, or be rescheduled.

✅ The nurse should document what the client consumed, how much was consumed, and the time of intake.

✅ The nurse should not independently decide to postpone surgery because that decision depends on the type of intake, timing, urgency of surgery, and anesthesia plan.

✅ The client should remain NPO until further instructions are received.

✅ Therefore, the safest and most appropriate action is to notify the anesthesiologist and surgeon promptly

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Answer 7

Correct Answers:

The client has developed confusion.

Rationale :

✅ Hypotonic IV fluids are used to treat hypernatremia by providing free water and lowering the serum sodium concentration.

✅ If hypernatremia is corrected too rapidly, water can move quickly into brain cells.

✅ This fluid shift can cause cerebral edema, which is a serious adverse effect.

✅ Confusion is an important neurologic manifestation that can indicate developing cerebral edema.

✅ Other concerning findings can include headache, lethargy, seizures, decreased level of consciousness, and neurologic deterioration.

✅ The nurse should closely monitor the client’s neurologic status and serum sodium level during treatment.

✅ Hypernatremia generally needs to be corrected gradually to reduce the risk of dangerous osmotic shifts.

✅ Therefore, new-onset confusion during hypotonic fluid replacement should be recognized as a possible adverse effect requiring prompt evaluation.

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Answer 8

Correct Answers:

Instruct the client about the use of a sequential compression device.

Rationale :

💠 Sequential compression devices (SCDs) help prevent postoperative venous thromboembolism (VTE), including deep-vein thrombosis.

💠 Major abdominal surgery and postoperative immobility increase the risk of venous stasis in the lower extremities.

💠 SCDs intermittently compress the legs, which promotes venous return toward the heart.

💠 Improved circulation reduces pooling of blood in the veins and decreases the likelihood of clot formation.

💠 Preoperative teaching helps the client understand why the device will be used and encourages cooperation after surgery.

💠 SCDs are often combined with early ambulation and prescribed anticoagulant prophylaxis when appropriate.

💠 Preventing DVT is important because a clot can dislodge and cause a potentially life-threatening pulmonary embolism.

💠 Therefore, teaching about SCD use directly addresses prevention of a significant postoperative complication.

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Answer 9

Correct Answers:

Assess the client's pain level and characteristics.

Rationale :

➡️ The nurse should first reassess the client’s pain before changing or adding interventions.

➡️ Pain assessment should include location, intensity, quality, onset, duration, aggravating factors, and relieving factors.

➡️ Persistent postoperative pain despite opioid therapy may indicate inadequate analgesia, a complication, or another source of discomfort.

➡️ Assessment helps determine whether the pain is expected surgical pain or something concerning, such as bleeding, infection, compartment pressure, or another postoperative complication.

➡️ The nurse should also assess the client’s sedation level, respiratory status, and previous response to opioid medication before giving more opioids.

➡️ Increasing the opioid dose without reassessment could increase the risk of respiratory depression, excessive sedation, hypotension, and other adverse effects.

➡️ Nonpharmacological measures can be useful, but they should be selected after determining the nature and severity of the pain.

➡️ Therefore, the priority is to assess the pain thoroughly before implementing additional treatment.

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Answer 10

Correct Answers:

Use emollients to soften scaling skin areas.

Rationale :

⏩ Emollients and moisturizers are an important part of psoriasis management because they help soften and loosen thick scales.

⏩ Psoriasis causes dry, erythematous plaques with silvery scales, so maintaining skin hydration can reduce cracking and irritation.

⏩ Regular use of emollients can decrease dryness, itching, and discomfort.

⏩ Moisturizers are especially helpful when applied after bathing while the skin is still slightly damp.

⏩ Keeping the skin hydrated also helps support the skin barrier and may improve the effectiveness of some topical treatments.

⏩ Clients should generally avoid harsh soaps and other products that excessively dry or irritate the skin.

⏩ Skin care should focus on reducing inflammation, preventing irritation, and maintaining moisture rather than treating pain alone.

⏩ Therefore, teaching the client to use emollients on scaling areas is appropriate.

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QLexNursing

1 :
A nurse is caring for a client who is 24 hours post-operative following abdominal surgery. The client reports feeling lightheaded and dizzy when attempting to sit up. What is the nurse's priority action?

2 :
A circulating nurse is precepting a new nurse in an outpatient surgery center, and they are assessing a client who has received moderate sedation. What action by the new nurse would require intervention by the circulating nurse?

3 :
A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

4 :
A nurse is providing teaching to a client who has had a biopsy of a superficial skin lesion that indicates malignant melanoma. The nurse should include which of the following options as the treatment of choice?

6 :
A nurse is preparing a client for surgery. During the preoperative assessment, the nurse discovers the client did not follow the preoperative fasting guidelines. What is the nurse's most appropriate action?

7 :
A nurse is caring for a client who has hypernatremia and is receiving intravenous (IV) hypotonic fluid replacement. Which of the following manifestations should the nurse understand is an indication of an adverse effect from the administration of hypotonic fluids

8 :
A nurse is providing preoperative teaching for a client who is scheduled for a subtotal gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in the teaching?

9 :
A nurse is managing a post-operative client who reports pain at the surgical site. The client has been receiving opioid analgesics but continues to experience pain. What is the nurse's best action?

10 :
A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan

QLexNursing

1 : A nurse is caring for a client who is 24 hours post-operative following abdominal surgery. The client reports feeling lightheaded and dizzy when attempting to sit up. What is the nurse's priority action?

2 : A circulating nurse is precepting a new nurse in an outpatient surgery center, and they are assessing a client who has received moderate sedation. What action by the new nurse would require intervention by the circulating nurse?

3 : A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

4 : A nurse is providing teaching to a client who has had a biopsy of a superficial skin lesion that indicates malignant melanoma. The nurse should include which of the following options as the treatment of choice?

6 : A nurse is preparing a client for surgery. During the preoperative assessment, the nurse discovers the client did not follow the preoperative fasting guidelines. What is the nurse's most appropriate action?

7 : A nurse is caring for a client who has hypernatremia and is receiving intravenous (IV) hypotonic fluid replacement. Which of the following manifestations should the nurse understand is an indication of an adverse effect from the administration of hypotonic fluids

8 : A nurse is providing preoperative teaching for a client who is scheduled for a subtotal gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in the teaching?

9 : A nurse is managing a post-operative client who reports pain at the surgical site. The client has been receiving opioid analgesics but continues to experience pain. What is the nurse's best action?

10 : A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan

1 :
A nurse is caring for a client who is 24 hours post-operative following abdominal surgery. The client reports feeling lightheaded and dizzy when attempting to sit up. What is the nurse's priority action?

2 :
A circulating nurse is precepting a new nurse in an outpatient surgery center, and they are assessing a client who has received moderate sedation. What action by the new nurse would require intervention by the circulating nurse?

3 :
A nurse is preparing a client for surgery. Which of the following is a priority when completing an assessment preoperatively?

4 :
A nurse is providing teaching to a client who has had a biopsy of a superficial skin lesion that indicates malignant melanoma. The nurse should include which of the following options as the treatment of choice?

6 :
A nurse is preparing a client for surgery. During the preoperative assessment, the nurse discovers the client did not follow the preoperative fasting guidelines. What is the nurse's most appropriate action?

7 :
A nurse is caring for a client who has hypernatremia and is receiving intravenous (IV) hypotonic fluid replacement. Which of the following manifestations should the nurse understand is an indication of an adverse effect from the administration of hypotonic fluids

8 :
A nurse is providing preoperative teaching for a client who is scheduled for a subtotal gastrectomy. Which of the following information regarding prevention of postoperative complications should the nurse include in the teaching?

9 :
A nurse is managing a post-operative client who reports pain at the surgical site. The client has been receiving opioid analgesics but continues to experience pain. What is the nurse's best action?

10 :
A nurse is developing a teaching plan for a client who has psoriasis. Which of the following information should the nurse include in the plan