Nokea
A nurse is obtaining a preoperative medical and surgical history from a patient scheduled for a cataract extraction procedure. Which of the following patient statements require further investigation by the nurse? Which statement requires further investigation pre-cataract surgery?
- A. I stopped taking aspirin last week.
- B. I took my blood pressure meds with a sip of water.
- C. I did not put my contact lenses in this morning.
- D. I had a cough and runny nose a couple days ago.
Correct Answer: D
Rationale: The correct answer is D because having a cough and runny nose a couple of days ago could indicate a potential respiratory infection, which may increase the risk of complications during surgery. The nurse should further investigate the severity and duration of the symptoms, as well as any current treatment or resolution.
A: Stopping aspirin last week is appropriate to reduce bleeding risk during surgery.
B: Taking blood pressure meds with water is standard practice and not concerning.
C: Not wearing contact lenses is normal before eye surgery to prevent complications.
In summary, choice D requires further investigation due to the possible impact on the patient's respiratory health, while the other choices are not directly related to the surgery or pose significant risks.
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A nurse is caring for a patient who has a new prescription for gabapentin. Which of the following adverse effects should the nurse monitor for? Which adverse effect should the nurse monitor for gabapentin?
- A. Drowsiness
- B. Hypertension
- C. Diarrhea
- D. Tachycardia
Correct Answer: A
Rationale: The correct answer is A: Drowsiness. Gabapentin is known to cause central nervous system side effects, such as drowsiness, dizziness, and fatigue. The nurse should monitor the patient for signs of drowsiness as it can impact their daily activities and safety. Hypertension (B), diarrhea (C), and tachycardia (D) are not commonly associated with gabapentin use. Therefore, the nurse should primarily focus on monitoring for drowsiness as the most likely adverse effect.
A nurse is caring for a toddler. The nurse's observations are as follows: Heart rate: 150/min, Temperature: 38.9°C (102°F), Respiratory rate: 28/min, Oxygen saturation: 96% on room air, Blood Pressure: 90/43 mm Hg. What should the nurse do next? What should the nurse do next for toddler vital signs?
- A. Monitor the toddler's vital signs closely.
- B. Administer supplemental oxygen.
- C. Notify the healthcare provider.
- D. Reassess the toddler in 15 minutes.
Correct Answer: A
Rationale: Rationale: Option A is correct as the toddler's vital signs are within acceptable ranges. The heart rate, respiratory rate, and oxygen saturation are normal for a toddler. The elevated temperature may indicate a fever, but it is not alarming. The blood pressure is slightly low but still acceptable. Therefore, the nurse should monitor the toddler's vital signs closely to assess for any changes. Administering oxygen, notifying the healthcare provider, or reassessing in 15 minutes are not necessary at this point as the vital signs do not indicate immediate concern. Monitoring closely allows for timely detection of any deterioration or improvement in the toddler's condition.
A nurse is caring for a patient who is receiving heparin by continuous IV infusion. Which of the following medications should the nurse plan to administer in the event of an overdose? Which medication should the nurse administer for heparin overdose?
- A. Vitamin K
- B. Iron
- C. Glucagon
- D. Protamine
Correct Answer: D
Rationale: The correct answer is D: Protamine. Protamine is the antidote for heparin overdose. It works by binding to heparin, neutralizing its anticoagulant effects. Vitamin K (choice A) is used to reverse the effects of warfarin, not heparin. Iron (choice B) is used to treat iron deficiency anemia. Glucagon (choice C) is used to treat hypoglycemia. In summary, protamine is specifically indicated for heparin overdose due to its ability to neutralize heparin's anticoagulant effects, making it the appropriate choice in this scenario.
Medical History (0700 hrs)
• Gestational age: 42 weeks
• Delivery: Spontaneous vaginal birth
• Amniotic fluid: Dark brown-greenish color noted
• Apgar scores: 8 at 1 minute, 9 at 5 minutes
Vital Signs (0700 hrs)
• Axillary temperature: 36.9°C (98.4°F)
• Heart rate: 170/min
• Respiratory rate: 72/min
• Birth weight: 4025 gm (8 lb 14 oz) (Appropriate for Gestational Age)
Nurses' Notes (0700 hrs)
The newborn was placed on the birth parent's abdomen immediately following delivery. The mouth and nose were suctioned with a bulb syringe to clear secretions. The newborn was dried and stimulated, resulting in a strong cry. The newborn was moving all extremities with a flexed tone noted. Acrocyanosis was present. The newborn was alert and active. Respirations were rapid and shallow with occasional expiratory grunting. Fine crackles were auscultated throughout the lung fields. A small amount of green- stained vernix was present in skin folds. The newborn had fingernails stained green. Molding of the skull and generalized soft occipital swelling were noted.
A nurse is caring for a newborn who is 30 minutes old following a spontaneous vaginal birth. The birth parent noted dark brown- greenish amniotic fluid during labor. The newborn was delivered at 42 weeks gestation. Apgar scores were 8 at 1 minute and 9 at 5 minutes. Exhibits After reviewing the information in the newborn's medical record, which of the following complications should the nurse identify as posing the greatest risk? Drag one condition and one client finding to fill in each blank in the following sentence.The condition that poses the greatest risk to the newborn is ---------------- due to -------------------
- A. Meconium aspiration syndrome
- B. Color of amniotic fluid
- C. Jaundice
- D. cold streets
- E. Birth Weight
Correct Answer: A,B
Rationale: Action to Take: A, B; Potential Condition: A; Parameter to Monitor: C, E.
Rationale:
- Meconium aspiration syndrome (MAS) is the correct answer as newborns exposed to meconium in amniotic fluid are at risk for respiratory distress.
- The color of amniotic fluid (brown-green) indicates presence of meconium, which can lead to MAS.
- Monitoring jaundice (C) is important as newborns with MAS may develop complications affecting liver function.
- Monitoring birth weight (E) is crucial as MAS can impact the newborn's overall health and growth.
Summary of Incorrect Choices:
- Jaundice (C): Although important to monitor, it is not the greatest risk in this scenario.
- Cold stress (D): Not relevant to the information provided about the newborn.
- Birth weight (E): While important to monitor, it is not the greatest risk posed by the scenario.
A nurse is caring for a patient who is postoperative following a mastectomy. Which of the following actions should the nurse take to promote comfort? Which action promotes comfort post-mastectomy?
- A. Elevate the affected arm.
- B. Apply a heating pad to the surgical site.
- C. Encourage deep breathing exercises.
- D. Administer NSAIDs around the clock.
Correct Answer: A
Rationale: The correct answer is A: Elevate the affected arm. Elevating the affected arm post-mastectomy helps reduce swelling and promote lymphatic drainage, which can alleviate discomfort and promote healing. Elevating the arm also helps improve circulation and prevent complications such as lymphedema.
Choice B: Applying a heating pad to the surgical site is not recommended post-mastectomy as it can increase the risk of burns and skin irritation.
Choice C: While deep breathing exercises are beneficial postoperatively to prevent complications such as pneumonia, it does not directly promote comfort in the context of a mastectomy.
Choice D: Administering NSAIDs around the clock may help manage pain post-mastectomy, but it does not specifically address comfort or promote physical comfort promotion strategies.