Nokea
An obstetrical client elects to have epidural anesthesia with Marcaine. After the epidural anesthesia is given, the nurse should monitor the client for signs of:
- A. Seizure activity
- B. Respiratory depression
- C. Postural hypotension
- D. Hematuria
Correct Answer: C
Rationale: Marcaine (bupivacaine) can cause vasodilation, leading to postural hypotension. Seizures, respiratory depression, and hematuria are less common.
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You are teaching a client about the patient controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?
- A. I will be receiving continuous doses of medication.
- B. I should call the nurse before I take additional doses.
- C. I will call for assistance if my pain is not relieved.
- D. The machine will prevent an overdose.
Correct Answer: B
Rationale: Patient controlled analgesia offers the client more control. The client should be instructed to initiate additional doses as needed without asking for assistance unless there is insufficient control of the pain.
A 19 year-old client is paralyzed in a car accident. Which statement used by the client would indicate to the nurse that the client is using the mechanism of 'suppression'?
- A. I don't remember anything about what happened to me.
- B. I'd rather not talk about it right now.
- C. It's all the other guy's fault! He was going too fast.
- D. My mother is heartbroken about this.
Correct Answer: A
Rationale: I don't remember anything about what happened to me. Suppression is willfully putting an unacceptable thought or feeling out of one's mind, used to protect one's self-esteem.
The nurse is caring for a client with a history of falls.
- A. Which intervention should be included in the care plan for a client with a history of falls?
- B. Keep the bed in a high position to discourage getting out of bed.
- C. Encourage the client to remain in bed as much as possible.
- D. Place a night light in the bathroom.
- E. Restrict the client’s fluid intake in the evening.
Correct Answer: C
Rationale: A night light in the bathroom reduces fall risk by improving visibility during nighttime ambulation, a common time for falls. High bed positions and bed rest increase fall risk, and fluid restriction is unrelated to fall prevention.
Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
- A. Sports and games with rules
- B. Finger paints and water play
- C. Dress-up clothes and props
- D. Chess and television programs
Correct Answer: A
Rationale: Sports and games with rules. The purpose of play for the 7 year-old is developing cooperation. Rules are very important. Logical reasoning and social skills are developed through play.
The nurse is caring for a client who is postoperative day 1 after a thyroidectomy. Which of the following findings should the nurse report immediately?
- A. Mild pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Heart rate of 80 bpm.
- D. Calcium level of 9.0 mg/dL.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-thyroidectomy complication. Options A, C, and D are normal or expected.