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A patient in the operating room has been administered succinylcholine and is now experiencing muscle rigidity and an extremely high temperature. What should the nurse do next?
- A. Call the PACU nurse to prepare for prolonged ventilatory support.
- B. Hold a prescription for dantrolene until the fever is reduced.
- C. Prepare ice packs for placement in the patient's axillary area.
- D. Determine if prescribed antibiotics were administered preoperatively.
- E. None
- F. None
Correct Answer: C
Rationale: Applying ice packs addresses hyperthermia in malignant hyperthermia, a critical response to succinylcholine-induced symptoms.
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While assessing a patient with degenerative joint disease, the nurse notices Heberden's nodes, and large prominences on the patient's fingers that are reddened and painful. What should the nurse do?
- A. Discuss strategies for managing chronic pain with the patient.
- B. Check the patient's radial pulses and capillary refill time.
- C. Immediately notify the healthcare provider of the finding.
- D. Review the patient's dietary intake of high-protein foods.
Correct Answer: A
Rationale: Discussing chronic pain management strategies addresses the discomfort associated with Heberden's nodes, a common osteoarthritis feature.
A client is diagnosed with chronic kidney disease and needs to begin dialysis. Which condition entered on the client's medical record should the nurse recognize as a contraindication for peritoneal dialysis?
- A. Latent hepatitis C.
- B. Crohn's disease with colectomy.
- C. History of nephrotic syndrome.
- D. Type 2 diabetes mellitus.
Correct Answer: B
Rationale: Crohn's disease with colectomy creates peritoneal adhesions, making peritoneal dialysis unsuitable.
The parent of an adolescent tells the clinic nurse, 'My child has athlete's foot. I have been applying triple antibiotic ointment for two days, but there has been no improvement.' Which instruction should the nurse provide?
- A. Antibiotics take two weeks to become effective against infections such as athlete's foot.
- B. Continue using the ointment for a full week, even after the symptoms disappear.
- C. Applying too much ointment can deter its effectiveness. Apply a thin layer to prevent maceration.
- D. Stop using the ointment and encourage complete drying of feet and wearing clean socks.
Correct Answer: D
Rationale: Athlete's foot is fungal, not bacterial; stopping antibiotic ointment and keeping feet dry with clean socks aids treatment.
Which group of foods should the nurse recommend for patients with a strong family history of colon and rectal cancers?
- A. Lean beef, salads, and baked potatoes.
- B. Potatoes, low-fat breads, and applesauce.
- C. Oatmeal, raisins, and fruit with skin.
- D. Chicken, rice, and wheat products.
Correct Answer: C
Rationale: Oatmeal, raisins, and fruit with skin are high in fiber, which supports gut health and reduces the risk of colorectal cancer.
A client arrives at the medical-surgical unit 4 hours after a transurethral resection of the prostate. A triple-lumen catheter for continuous bladder irrigation with normal saline is infusing and the nurse observes dark, pink-tinged outflow with blood clots in the tubing and collection bag. Which action should the nurse take?
- A. Decrease the flow rate.
- B. Irrigate the catheter manually.
- C. Discontinue infusing solution.
- D. Monitor catheter drainage.
Correct Answer: B
Rationale: Manual irrigation dislodges blood clots, ensuring catheter patency and preventing urinary obstruction.