Nokea
A 250-lb male client recovering from general anesthesia has the following assessment findings: pulse, 150 bpm; blood pressure, 90/50 mm Hg; respiratory rate, 28 breaths/minute; tympanic temperature, 99.8°F (37.7°C); and rigid muscles. The nurse determines that the client is:
- A. Recovering as expected from the anesthesia and continues monitoring him.
- B. Exhibiting the effects of excessive blood loss experienced in the operating room and increases the rate of his I.V. infusion.
- C. In the early stages of malignant hyperthermia and obtains emergency medications and notification.
- D. In pain and offers him pain medication.
Correct Answer: C
Rationale: Tachycardia, hypotension, tachypnea, and muscle rigidity suggest malignant hyperthermia, a life-threatening reaction to anesthesia. Immediate action, including emergency medications like dantrolene, is required.
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- C. Expect to stay overnight in the hospital.
- D. Empty the bladder before the procedure.
Correct Answer: D
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- A. Fair skin and history of chronic sun exposure.
- B. Caucasian race and history of hypertension.
- C. Dark skin and family history of skin cancer.
- D. Dark skin and history of hypertension.
Correct Answer: A
Rationale: Fair skin and chronic sun exposure increase skin cancer risk due to higher UV sensitivity and cumulative damage. Dark skin offers some protection.
What is the priority nursing action for a client with a suspected brain tumor?
- A. Administer pain medication.
- B. Monitor neurological status.
- C. Provide emotional support.
- D. Restrict physical activity.
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A client with a new ileostomy is concerned about returning to work. Which advice should the nurse provide to support the client's transition?
- A. Wear loose clothing to conceal the pouch.
- B. Avoid all physical activity for 6 months.
- C. Change the pouch daily regardless of output.
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Correct Answer: A
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- A. Sodium phosphate.
- B. Calcium gluconate.
- C. Echothiophate iodide.
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Correct Answer: B
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