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A client returned to the recovery room after a dilatation and curettage has the postoperative medication orders shown in the chart. What should the nurse do next?
- A. Ask the client to rate the intensity of her painon a scale of 1 to 10 and administer the analgesia according to the intensity of the pain.
- B. Administer the Demerol fi rst because the client had surgery today.
- C. Administer the Tylenol #3 fi rst, and if it does not relieve the pain in 2 hours, administer the Demerol.
- D. Administer the Motrin fi rst and if it does not relieve the pain, administer the Demerol.
Correct Answer: A
Rationale: The nurse must fi rst assess the intensity of the client’s pain before selecting the correct analgesia. A high score would necessitate administering the meperidine (Demerol). If the intensity rating is low, an oral analgesic would be appropriate. If acetaminophen (Tylenol #3) is given without assessing the intensity of the client’s pain, the nurse must then wait 4 hours before administering another analgesic
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Which intervention is appropriate for a client on hemodialysis?
- A. Check fistula for a thrill.
- B. Restrict all fluids.
- C. Administer heparin post-dialysis.
- D. Encourage high-protein diet.
Correct Answer: A
Rationale: Checking for a thrill ensures fistula patency for dialysis.
When caring for the client who is receiving an aminoglycoside antibiotic, the nurse should monitor which of the following laboratory values?
- A. Serum sodium.
- B. Serum potassium.
- C. Serum creatinine.
- D. Serum calcium.
Correct Answer: C
Rationale: Aminoglycosides are nephrotoxic; monitoring serum creatinine assesses kidney function. Sodium, potassium, and calcium are not primarily affected by aminoglycosides.
Which safety measures would be most important to implement when caring for a client who is receiving 2 units of packed red blood cells (PRBCs)? Select all that apply.
- A. Verify that the ABO and Rh of the 2 units are the same.
- B. Infuse the unit of PRBCs in less than 4 hours.
- C. Stop the transfusion if a reaction occurs, but keep the line open.
- D. Take vital signs every 15 minutes while the unit is transfusing.
- E. Inspect the blood bag for leaks, abnormal color, and clots.
- F. Use a 22-gauge catheter for optimal flow of a blood transfusion.
Correct Answer: A,B,C,E
Rationale: Key safety measures for PRBC transfusion include verifying ABO and Rh compatibility to prevent reactions, infusing within 4 hours to reduce infection risk, stopping the transfusion if a reaction occurs while keeping the line open, and inspecting the blood bag for abnormalities. Taking vital signs every 15 minutes is excessive (typically every 15 minutes for the first 15 minutes, then hourly). A 22-gauge catheter is too small; a larger gauge (18–20) is needed for optimal flow.
The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)?
- A. Dizziness.
- B. Biliary colic.
- C. Bleeding.
- D. Urine retention.
Correct Answer: A
Rationale: Naloxone can cause dizziness due to rapid reversal of opioid effects, leading to autonomic changes. This is a common side effect to monitor in surgical clients.
The nurse is aware that the diagnostic tests typically ordered for acute diverticulitis do not include a barium enema. The reason for this is that a barium enema:
- A. Can perforate an intestinal abscess.
- B. Would greatly increase the client's pain.
- C. Is of minimal diagnostic value in diverticulitis.
- D. Is too lengthy a procedure for the client to tolerate.
Correct Answer: A
Rationale: A barium enema is avoided in acute diverticulitis because it can perforate an intestinal abscess, worsening the condition. It may cause discomfort but is not primarily avoided for pain, diagnostic value, or procedure length. CN: Reduction of risk potential; CL: Apply