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A client complaining of numbness from the back of his left buttock to the dorsum of his foot and big toe is scheduled to undergo a laminectomy. The operative consent form states, 'a left lumbar laminectomy of L3-4.' Which of the following should the nurse do next?
- A. Have the client sign the consent form.
- B. Call the surgeon.
- C. Change the consent form.
- D. Review the client's history.
Correct Answer: B
Rationale: The consent form must match the client's symptoms, which suggest L5-S1 involvement, not L3-4. The surgeon must clarify.
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A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
- A. Check the tubing to ensure that the client is not lying on it or kinking it.
- B. Increase the suction.
- C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest.
- D. Ensure that the chest tube has two clamps on it to prevent air leaks.
Correct Answer: A
Rationale: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.
A client with acute renal failure has a low calcium level. The nurse should monitor for:
- A. Tetany.
- B. Hypertension.
- C. Bradycardia.
- D. Edema.
Correct Answer: A
Rationale: Low calcium can cause tetany, manifesting as muscle cramps or spasms.
When instructing a client who has been newly diagnosed with vasospastic disorder (Raynaud's phenomenon) about management of care, the nurse should discuss which of the following topics?
- A. Scheduling a sympathectomy procedure for the next visit
- B. Using a beta blocker medication
- C. Follow-up monitoring for development of connective tissue disease
- D. Benefit of an angioplasty to the affected extremities
Correct Answer: C
Rationale: Raynaud's phenomenon is often associated with connective tissue diseases (e.g., scleroderma, lupus), especially secondary Raynaud's. Discussing follow-up monitoring for these conditions is essential for early detection and management. Sympathectomy, beta blockers, and angioplasty are not first-line or relevant interventions.
The physician ordered I.V. naloxone (Narcan) to reverse the respiratory depression from morphine administration. After administration of the naloxone the nurse should:
- A. Check respirations in 5 minutes because naloxone is immediately effective in relieving respiratory depression.
- B. Check respirations in 30 minutes because the effects of morphine will have worn off by then.
- C. Monitor respirations frequently for 4 to 6 hours because the client may need repeated doses of naloxone.
- D. Monitor respirations each time the client receives morphine sulfate 10 mg I.M.
Correct Answer: C
Rationale: Naloxone has a shorter half-life than morphine, so respiratory depression may recur. Frequent monitoring for 4-6 hours ensures timely detection and additional doses if needed.
Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
- A. Sore throat.
- B. Painful, excessive menstruation.
- C. Constipation.
- D. Increased urine output.
Correct Answer: A
Rationale: Propylthiouracil (PTU) can cause agranulocytosis, a serious condition involving a low white blood cell count, which may present as a sore throat or fever. This requires immediate reporting. The other symptoms are not typically associated with PTU side effects.