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An elderly man has just returned from the operating room where he spent several hours in lithotomy position during a perineal prostatectomy. Which assessment should the nurse make because the client was in lithotomy position during surgery?
- A. Lower extremity pulses, paresthesias, and pain
- B. The presence of bowel sounds
- C. Radial pulse, sensation, and movement of the arms
- D. Palpation of the bladder
Correct Answer: A
Rationale: Prolonged lithotomy position risks nerve compression and impaired circulation in the lower extremities, necessitating assessment of pulses, paresthesias, and pain to detect complications like compartment syndrome.
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The client has been receiving garamycin 65 mg IVPB every 8 hours for the past 6 days. Which lab result indicates an adverse reaction to the medication?
- A. WBC 7500
- B. Serum glucose 92
- C. Protein 3.5
- D. Serum Creatinine 2.0
Correct Answer: D
Rationale: Garamycin (gentamicin) is an aminoglycoside antibiotic that can cause nephrotoxicity. A serum creatinine level of 2.0 mg/dL is elevated (normal range is approximately 0.6-1.2 mg/dL), indicating potential kidney damage, an adverse reaction. Answers A, B, and C represent normal or unrelated lab values.
While sitting at the nurse's station, the nurse observes that a client uses a tissue to pick up magazines and change channels on the television. There has been no such behavior in the past. The nurse should:
- A. Talk with the client about the behavior.
- B. Provide the client with a pair of nonsterile gloves.
- C. Take the tissues away from the client.
- D. Recognize the behavior as a means of getting attention.
Correct Answer: A
Rationale: Talking with the client assesses potential obsessive-compulsive behavior or anxiety. Gloves or removing tissues may escalate distress. Attention-seeking is an assumption without evidence.
A client with newly diagnosed chronic heart failure is being discharged home. Which statement(s) by the client indicate a need for further teaching by the nurse? Select all that apply.
- A. I don't plan on eating any more frozen meals.'
- B. I plan to take my diuretic pill in the morning.'
- C. I will weigh myself at least every other day.'
- D. I'm going to look into joining a cardiac rehabilitation program.'
- E. Ibuprofen works best for me when I have pain.'
Correct Answer: E
Rationale: Ibuprofen can cause fluid retention, worsening heart failure, and requires further teaching. Avoiding frozen meals , morning diuretic , regular weighing , and cardiac rehab are appropriate.
The nurse in a clinic is caring for an 8-month-old client with a new diagnosis of bronchiolitis due to respiratory syncytial virus. Which of the following instructions should the nurse provide to the parent?
- A. Administration of a cough suppressant and an antihistamine
- B. Prophylactic treatment of family members
- C. Temporary cessation of breastfeeding
- D. Use of saline drops and a bulb syringe to suction nares
Correct Answer: D
Rationale: For bronchiolitis due to RSV, saline drops and bulb syringe suctioning help clear nasal passages, improving breathing. Cough suppressants and antihistamines are not recommended as they may suppress necessary cough or cause sedation. Prophylactic treatment is not standard for family members unless immunocompromised, and breastfeeding should continue to provide antibodies.
While assessing the vital signs in children, the nurse should know that the apical heart rate is preferred until the radial pulse can be accurately assessed at about what age?
- A. 1 year of age
- B. 2 years of age
- C. 3 years of age
- D. 4 years of age
Correct Answer: B
Rationale: 2 years of age. A child should be at least 2 years of age to use the radial pulse to assess heart rate.