Nokea
A client who collapsed during dinner in a restaurant arrives in the emergency department. The client is going to surgery to repair an abdominal aortic aneurysm. What medication does the nurse prepare to administer as a priority with this client?
- A. Hydrocodone (Vicodin)
- B. Lorazepam (Ativan)
- C. Metoclopramide (Reglan)
- D. Morphine sulfate (Morphine)
Correct Answer: C
Rationale: Metoclopramide (Reglan) increases gastric emptying, an important issue for this client who was eating just prior to the operation to reduce the risk of aspiration. The other drugs are appropriate for pain or anxiety management but are not the priority in this scenario.
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A nursing instructor is teaching students about different surgical procedures and their classifications. Which procedures are correctly classified?
- A. Hemicolectomy: diagnostic
- B. Liver biopsy: diagnostic
- C. Spinal cord decompression: palliative
- D. Total shoulder replacement: restorative
- E. Mastectomy: restorative
Correct Answer: B,E
Rationale: A diagnostic procedure is used to determine cell type of cancer and to determine the cause of a problem, such as a liver biopsy. A restorative procedure aims to improve functional ability, such as a total shoulder replacement. A curative procedure either removes or repairs the causative problem, such as a mastectomy or hemicolectomy, which are not diagnostic or palliative.
A preoperative nurse is reviewing morning laboratory values on four clients waiting for surgery. Which result warrants immediate communication with the surgical team?
- A. Creatinine 2 mg/dL
- B. Potassium 3.8 mEq/L
- C. Hemoglobin 12 g/dL
- D. Platelet count 150,000/mm³
Correct Answer: A
Rationale: A creatinine level of 2 mg/dL is elevated, indicating potential renal impairment, which can affect anesthesia and surgical outcomes. This warrants immediate communication with the surgical team. The other values are within normal ranges and do not require urgent reporting.
A client in the preoperative holding room has received sedation and now needs to urinate. What action by the nurse is best?
- A. Allow the client to walk to the bathroom
- B. Assist the client to the bathroom
- C. Give the client a bedpan or urinal to use
- D. Insert a urinary catheter now instead of waiting
Correct Answer: C
Rationale: Although possibly uncomfortable or embarrassing for the client, the client should not be allowed out of bed after sedation due to safety concerns. Providing a bedpan or urinal is the safest option. The client may or may not need a urinary catheter, depending on the surgical procedure.
A clinic nurse is teaching a client prior to surgery. The client does not seem to comprehend the teaching, forgets a lot of what is said, and asks the same questions again and again. What action by the nurse is best?
- A. Assess the client for anxiety
- B. Break the information into smaller bits
- C. Give the client written information
- D. Request the provider to repeat the information
Correct Answer: A
Rationale: Anxiety can interfere with learning and cooperation. The nurse should assess the client for anxiety. The other actions are appropriate too, and can be included in the teaching plan, but effective teaching cannot occur if the client is highly anxious.
A nurse works on the postoperative floor and has four clients who are being discharged tomorrow. Which one has the greatest need for the nurse to consult other members of the health care team for post-discharge care?
- A. Married young adult who is the primary caregiver for children
- B. Middle-aged client who is post long time replacement, needs physical therapy
- C. Older adult who lives at home despite some memory loss
- D. Young client who lives alone, has family and friends nearby
Correct Answer: C
Rationale: The older adult has the most potentially complex discharge needs. With memory loss, the client may not be able to follow the prescribed home regimen. The client's physical abilities may be limited by chronic illness. This client has several safety needs that should be assessed. The other clients all have evidence of a support system and no known potential for serious safety issues.