A client with impaired cardiac functioning is at risk during anesthesia induction with thiopental sodium (Sodium Pentothal) because this drug causes:
- A. Bradycardia.
- B. Complete muscle relaxation.
- C. Hypotension.
- D. Tachypnea.
Correct Answer: C
Rationale: Thiopental can cause hypotension, which is particularly risky in clients with impaired cardiac function, as it may exacerbate cardiovascular instability during induction.
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To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:
- A. Lying supine.
- B. Coughing.
- C. Deep breathing.
- D. Ambulation.
Correct Answer: B
Rationale: Coughing increases intraocular pressure by causing a Valsalva maneuver, which can strain the surgical site and lead to complications like hemorrhage or wound dehiscence.
A nurse has two clients that have an order to receive a blood transfusion of packed red blood cells at the same time. The first client's blood pressure dropped from the preoperative value of 120/80 mm Hg to a postoperative value of 100/50. The second client is 58 years old and is hospitalized because he developed dehydration and anemia following pneumonia. After checking the patency of their I.V. lines and vital signs, which should the nurse do next?
- A. Call for both clients' blood transfusions at the same time.
- B. Ask the nurse to verify the compatibility of both units at the same time.
- C. Call for and hang the first client's blood transfusion.
- D. Ask another nurse to call for and hang the blood for the second client.
Correct Answer: C
Rationale: The first client's significant blood pressure drop (120/80 to 100/50) indicates potential hypovolemia or bleeding, making their transfusion a priority to restore volume and oxygen-carrying capacity. The second client's condition is less urgent. The nurse should call for and hang the first client's transfusion first.
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
- A. Turning every 2 hours
- B. Passive and active range-of-motion exercises
- C. Use of thromboembolic disease support (TED) hose
- D. Maintaining the client in the supine position
Correct Answer: D
Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.
The nurse is preparing a client for a paracentesis. The nurse should:
- A. Have the client void immediately before the procedure.
- B. Place the client in a side-lying position.
- C. Initiate an I.V. line to administer sedatives.
- D. Place the client on nothing-by-mouth (NPO) status 6 hours before the procedure.
Correct Answer: A
Rationale: Voiding before paracentesis (A) prevents bladder injury. Side-lying (B) is incorrect; upright is preferred. IV sedatives (C) are not routine, and NPO (D) is unnecessary.
To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to:
- A. Rinse the mouth with saline solution.
- B. Perform frequent toothbrushing.
- C. Clean the teeth with an electric toothbrush.
- D. Floss the teeth thoroughly.
Correct Answer: A
Rationale: Saline mouth rinses are gentle and safe post-transsphenoidal hypophysectomy, avoiding irritation to the surgical site.
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