Nokea
A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:
- A. Infection postoperatively
- B. Malignant hyperthermia
- C. Neuroleptic malignant syndrome
- D. Fever postoperatively
Correct Answer: B
Rationale: Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia.
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A client is receiving peritoneal dialysis. He has been taught to warm the dialyzing fluid prior to instilling it because:
- A. Warmed solution helps keep the body temperature maintained within a normal range during instillation
- B. Warmed solution helps dilate the peritoneal blood vessels
- C. Warmed solution decreases the risk of peritoneal infection
- D. Warmed solution promotes a relaxed abdominal muscle
Correct Answer: B
Rationale: Instilling a cool solution does not significantly lower the body temperature during peritoneal dialysis. Warmed solution does help dilate the peritoneal blood vessels, facilitating the exchange of fluids. Warming the dialysate does not decrease the risk of peritoneal infection. Sterile technique decreases this risk. Relaxing the abdominal muscles does not facilitate peritoneal dialysis.
The nurse is caring for a client in labor. The fetal monitor shows early decelerations. The nurse should:
- A. Notify the physician immediately
- B. Reposition the client to her left side
- C. Continue to monitor the fetal heart rate
- D. Administer oxygen at 8-10 liters per minute
Correct Answer: C
Rationale: Early decelerations are benign caused by fetal head compression during contractions and do not indicate fetal distress. Continuing to monitor the fetal heart rate is appropriate. Repositioning oxygen or notifying the physician are unnecessary unless other abnormalities occur.
A violent client remains in restraints for several hours. Which of the following interventions is most appropriate while he is in restraints?
- A. Give fluids if the client requests them.
- B. Assess skin integrity and circulation of extremities before applying restraints and as they are removed.
- C. Measure vital signs at least every 4 hours.
- D. Release restraints every 2 hours for client to exercise.
Correct Answer: D
Rationale: Restraints should be released every 2 hours for exercise, one extremity at a time, to maintain muscle tone, skin and joint integrity, and circulation.
The chart indicates that a client has expressive aphasia following a stroke. The nurse understands that the client will have difficulty with:
- A. Speaking and writing
- B. Comprehending spoken words
- C. Carrying out purposeful motor activity
- D. Recognizing and using an object correctly
Correct Answer: A
Rationale: Expressive aphasia (Broca’s aphasia) impairs the ability to speak and write due to damage in the frontal lobe’s speech center. Comprehension and motor activity are less affected.
A client telephones the emergency room stating that she thinks that she is in labor. The nurse should tell the client that labor has probably begun when:
- A. Her contractions are two minutes apart.
- B. She has back pain and a bloody discharge.
- C. She experiences abdominal pain and frequent urination.
- D. Her contractions are five minutes apart.
Correct Answer: D
Rationale: Contractions five minutes apart lasting 30-60 seconds indicate the onset of active labor. Two-minute contractions suggest advanced labor and back pain or urination are less specific signs.