Complex Care Flashcards

A client post-abdominal surgery reports sudden severe abdominal pain with board-like rigidity. What is the priority nursing action?

Answer: Position in semi-Fowlers and notify the physician immediately

Sudden severe pain with abdominal rigidity post-surgery suggests peritonitis or anastomotic leak requiring immediate medical intervention.

A client with Type 1 diabetes has blood glucose 2.8 mmol/L with diaphoresis and trembling. Which intervention has priority?

Answer: Give 15 grams of fast-acting carbohydrate if the client can swallow safely

A conscious client with symptomatic hypoglycemia receives 15g fast-acting carbohydrate first (15-15 rule).

A client with chronic renal failure on a potassium-restricted diet selects which food that requires correction?

Answer: Orange juice and a banana

Oranges and bananas are high-potassium foods contraindicated in clients with chronic renal failure on potassium restriction.

A client develops chills, fever, and back pain 20 minutes into a blood transfusion. What is the first nursing action?

Answer: Stop the transfusion immediately and maintain IV access with normal saline

Signs of transfusion reaction require immediately stopping the transfusion while maintaining IV access with normal saline.

A client with left-sided stroke has left hemiplegia and dysphagia. Which meal positioning is most appropriate?

Answer: Upright at 90 degrees with head turned toward the weaker side

Upright 90 degrees with head turned to the weak side closes that side of the pharynx, directing the food bolus to the stronger side.

A family member is about to activate the PCA button for a sleeping client. What is the correct nursing response?

Answer: Educate the family that only the client should activate the PCA and explain the safety reasons

PCA by proxy bypasses the built-in safety mechanism where only an awake, alert client can press the button, risking respiratory depression.