Module 9Questions1.1.ID: 283576085A nurse is caring for a client who has just regained bowel sounds after undergoing surgery. The physician has prescribed a clear liquid diet for the client. Which of the following items does the nurse ensure is available in the client’s room before allowing the client to drink? Straw Napkin Suction equipment Correct Oxygen saturation monitor Rationale:Aspiration is a concern when fluids are offered to a client who has just undergone surgery. It is possible that the swallow reflex is still impaired as an effect of anesthesia. The nursechecks the gag and swallow reflexes before offering fluids to the client, but suction equipment still must be available. An oxygen saturation monitor is unnecessary when fluids are being administered, nor is a napkin or straw necessary; in fact, the straw could contribute to the formation of flatus, resulting in gastrointestinal discomfort.Test-Taking Strategy:The subject of the question is protecting the client’s gag and swallow reflexes. Use your knowledge of the ABCs (airway, breathing, and circulation) to answer this question. The correct option helps maintain airway clearance. If you had difficulty with this question, review care of the client who has recently undergone surgery.Level of Cognitive Ability:ApplyingClient Needs:Physiological Integrity Integrated Process:Nursing Process/PlanningContent Area:Perioperative Care
References:Ignatavicius, D., & Workman, M. (2010). Medical-surgical nursing: Patient-centered collaborative care(6th ed., pp. 290, 291). St. Louis: Saunders.Potter, P., & Perry, A. (2009). Fundamentals of nursing(7thed., p. 1103). St. Louis: Mosby. Awarded 1.0 points out of 1.0 possible points. 2.2.ID: 283576977A client has undergone renal angiography by way of the right femoral artery. The nurse determines that the client is experiencing a complication of the procedure on noting: Urine output of 40 mL/hr Blood pressure of 118/76 mm Hg Respiratory rate of 18 breaths/min Pallor and coolness of the right leg Correct Rationale:Complications of renal angiography include allergic reaction to the dye, dye-induced renal damage, and a number of vascular complications, including hemorrhage, thrombosis, and embolism. The nurse detects these complications by monitoring the client for signs and symptoms of allergic reaction, decreased urine output, hematoma or hemorrhage at the insertion site, and signs of diminished circulation to the affected leg. The incorrect options are normal findings.Test-Taking Strategy:Use the process of elimination and note the words “a complication of the procedure,” which should tell you that the correct option is an abnormal assessment finding. Eliminate the incorrect options, because they are normal findings. Pallor and coolness indicate thrombosis or hematoma and should be further assessed and reported. Review the signs of complications after renal angiography if you had difficulty with this question.