Nokea
A client has been administered ketamine by a physician in preparation for general anesthesia. Which of the following side effects should the nurse monitor for in this client?
- A. Delirium
- B. Muscle rigidity
- C. Hypotension
- D. Pinpoint rash
Correct Answer: A
Rationale: Ketamine is an anesthetic that induces dissociation and lack of awareness in a client. It can be used before general anesthesia or during short procedures for sedation. Ketamine may lead to side effects such as delirium, hallucinations, hypertension, and respiratory depression. Therefore, the nurse should monitor the client for delirium, as it is a potential side effect associated with ketamine use. Muscle rigidity, hypotension, and pinpoint rash are not typically attributed to ketamine administration and are less likely to occur in this scenario.
You may also like to solve these questions
The community health nurse has reviewed information about the population of a local community and has determined that there are groups in the population that are at high risk for infection with tuberculosis (TB). The nurse targets which high-risk group for screening?
- A. French Canadians
- B. White, Anglo-Saxon Americans
- C. Older clients in long-term-care facilities
- D. Adolescents between the ages of 13 and 17 years
Correct Answer: C
Rationale: Older clients in long-term-care facilities are at high risk for TB due to age-related immune decline and close living conditions. French Canadians, White Anglo-Saxon Americans, and adolescents are not specifically high-risk groups unless other factors apply.
The nurse is teaching a client about dietary modifications to control hypertension. Which statement by the client indicates a need for further teaching?
- A. I can have a cup of fresh fruit as a snack.
- B. Baked ham is a good dinner choice for me.
- C. I need to check the label for sodium in ketchup.
- D. I need to cut out frozen pizza as a fast meal option.
Correct Answer: B
Rationale: Baked ham is high in sodium, which is unsuitable for hypertension. Other choices align with low-sodium dietary recommendations.
A healthcare professional is preparing to draw a blood specimen from an adult client's central line. All of the following actions for this procedure are correct EXCEPT:
- A. Disconnect the current infusion
- B. Clean the cap with alcohol and attach a 5 cc syringe
- C. Draw 5 cc of a blood sample to discard
- D. Flush with saline after the sample
Correct Answer: B
Rationale: When drawing a blood specimen from a central line, the healthcare professional should disconnect any infusions that are currently running and that could contaminate the specimen. It is important to use a minimum size of a 10 cc syringe when using a central line to avoid placing too much pressure on the catheter. Cleaning the cap with alcohol and attaching a 5 cc syringe is not appropriate as a larger syringe size should be used for this procedure. Drawing 5 cc of a blood sample to discard and flushing with saline after the sample are correct steps in the process of drawing a blood specimen from a central line.
A client who is taking an antipsychotic medication is preparing for discharge. To facilitate health promotion for this client, what instruction should the nurse provide?
- A. Avoid prolonged exposure to the sun.
- B. Adhere to a strict tyramine-restricted diet.
- C. Recognize the signs and symptoms of a relapse of depression.
- D. Have therapeutic blood levels drawn because the medication has a narrow therapeutic range.
Correct Answer: A
Rationale: Antipsychotic medications improve the thought processes and behaviors of a client with psychotic symptoms, especially a client with schizophrenia. Photosensitivity is a side effect of antipsychotic medications. Maintaining a strict tyramine-restricted diet is applicable to monoamine oxidase inhibitors (MAOIs). Antipsychotics are not used to treat depression. Lithium is a mood stabilizer that requires monitoring of medication blood levels.
The nurse has taught a client with a below-the-knee amputation about home care and about monitoring for and preventing complications related to prosthesis and residual limb care. The nurse determines that the client has understood the instructions if the client stated that which action should be taken?
- A. Wear a clean nylon sock over the residual limb every day.
- B. Use a mirror to inspect all areas of the residual limb each day.
- C. Toughen the skin of the residual limb by rubbing it with alcohol.
- D. Prevent cracking of the skin of the residual limb by applying lotion daily.
Correct Answer: B
Rationale: The client should inspect all surfaces of the residual limb daily for irritation, blisters, and breakdown. The client should wear a clean woolen (not nylon) sock each day. The residual limb is cleansed daily with a gentle soap and water and dried carefully. Alcohol is avoided because it could cause drying or cracking of the skin. Oils and creams are also avoided because they are too softening to the skin for safe prosthesis use.