A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanasthesia unit. Before selecting which medication to administer, which action should the nurse implement?
- A. Document the client's report of pain in the electronic medical record
- B. Determine which prescription will have the quickest onset of action
- C. Compare the client's pain scale rating with the prescribed dosing
- D. Ask the client to choose which mediation is needed for pain
Correct Answer: C
Rationale: Comparing the pain scale rating with the prescribed dosing ensures that the appropriate medication is administered based on the severity of the pain.
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All the following are correct about left ventricular assist device implantation, except
- A. LA pressure is reduced more than RA pressure
- B. A PFO/small ASD is created following LVAD implantation for decompressing LA
- C. Right to left shunting at atrial level can produce systemic desaturation
- D. RV failure is a bad prognostic marker
Correct Answer: B
Rationale: A PFO/small ASD is not typically created following LVAD implantation.
An adult female with multiple sclerosis (MS) falls while walking to the bathroom. On transfer to the intensive care unit, she is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?
- A. Determine client's last dose of corticosteroids
- B. Determine neurological baseline prior to the fall
- C. Administer a PRN IV antiemetic as prescribed
- D. Complete head to toe neurological assessment.
Correct Answer: D
Rationale: The symptoms suggest increased intracranial pressure or a neurological emergency. A thorough neurological assessment is necessary to identify the cause and guide further interventions.
In 90% of cases of endocarditis, the causative agent is recovered from the first 2 blood cultures. Antimicrobial pretreatment of the patient reduces the yield of blood cultures to
- A. 10%
- B. 20%
- C. 30%
- D. 40%
Correct Answer: A
Rationale: Antimicrobial pretreatment can significantly reduce the yield of blood cultures, often to 10-20%.
What are THREE long-term complications in repaired Tetralogy of Fallot?
- A. Arrhythmia
- B. Pulmonary valve insufficiency
- C. Sudden Death
- D. Recurrent PS
Correct Answer: D
Rationale: Patients with repaired Tetralogy of Fallot are at risk of long-term complications such as recurrent pulmonary stenosis, arrhythmias, and valve insufficiencies.
Avascular necrosis of the femoral head is associated with:
- A. Sickle cell trait
- B. Nephrotic syndrome
- C. Cushing's syndrome
- D. Hypothyroidism
Correct Answer: C
Rationale: Cushing's syndrome is associated with avascular necrosis due to steroid use. Sickle cell trait, nephrotic syndrome, and hypothyroidism are not directly linked.