Nokea
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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After a transurethral resection of the prostate (TURP), a client has bloody urine output with large clots. The nurse implements the postoperative prescription to irrigate the indwelling catheter PRN to maintain the catheter's patency. Which action should the nurse implement?
- A. Clamp the catheter for 30 minutes prior to irrigating with saline
- B. Manually irrigate the catheter with sterile saline as prescribed
- C. Increase the client's oral fluid intake to flush out clots naturally
- D. Remove the catheter and notify the healthcare provider immediately
Correct Answer: A
Rationale: Clamping the catheter before irrigation prevents sudden fluid shifts and ensures that irrigation is performed effectively.
Regarding coarctation of aorta
- A. Associated with Turner's syndrome
- B. Commonest is preductal type
- C. Radio femoral delay is a feature
- D. Systolic BP in lower limb is higher than in upper limb
Correct Answer: C
Rationale: Radio-femoral delay is a characteristic feature of coarctation of the aorta due to the obstruction in blood flow.
The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure?
- A. Light yellow coloring of the client's skin and eyes
- B. The client's blood pressure reading is 184/88 mm Hg.
- C. The client vomits 20 ml of clear yellowish fluid
- D. The IV insertion site is red, swollen, and leaking IV fluid
Correct Answer: B
Rationale: High blood pressure increases the risk of complications during surgery and needs to be addressed before proceeding.
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.
A 2-month-old male presents with tachycardia, dyspnea, tachypnea, and a gallop rhythm with no heart murmur. He was perfectly well until 1 day prior to the episode. The physical examination reveals a heart rate of 235, a temperature of 37.8°C, and a normal blood pressure with warm, well-perfused extremities. The most likely diagnosis is
- A. sepsis
- B. supraventricular tachycardia
- C. ingestion
- D. ventricular tachycardia
Correct Answer: B
Rationale: Supraventricular tachycardia can cause rapid heart rates and heart failure in infants.