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An operating room nurse just received a client scheduled for a laparoscopic cholecystectomy, but discovers the consent form has not been signed. What is the most appropriate action?
- A. bring the client a new consent form and have him sign it right away
- B. call the surgeon and ask how she would like to proceed
- C. inform the nursing manager there is no signed consent form
- D. ask the unit manager if the surgery can be rescheduled for later in the day
Correct Answer: B
Rationale: Missing consent requires notifying the surgeon to ensure the client is informed and consents before proceeding, adhering to legal and ethical standards.
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After abdominal surgery, a client has a nasogastric tube attached to low suctioning. The client becomes nauseated, and the nurse observes a decrease in the flow of gastric secretions. Which of the following nursing interventions would be MOST appropriate?
- A. Irrigate the nasogastric tube with distilled water.
- B. Aspirate the gastric contents with a syringe.
- C. Administer an antiemetic medicine.
- D. Insert a new nasogastric tube.
Correct Answer: B
Rationale: to confirm placement, nurse should aspirate and test the pH of the aspirate, results should be 0-4
The nurse is caring for a child with Down syndrome. Which characteristics are commonly found in the child with Down syndrome?
- A. Fragile bones, blue sclera, and brittle teeth
- B. Epicanthal folds, broad hands, and transpalmar creases
- C. Low posterior hairline, webbed neck, and short stature
- D. Developmental regression and cherry-red macula
Correct Answer: B
Rationale: Down syndrome is characterized by epicanthal folds, broad hands, and transpalmar creases.
The nurse is assessing an ECG strip of a 42-year-old client and finds a regular rate greater than 100, a normal QRS complex, a normal P wave in front of each QRS, a PR interval between 0.12 and 0.20 seconds, and a P: QRS ratio of 1:1. What is the nurse's interpretation of this rhythm?
- A. Premature atrial complex
- B. Sinus tachycardia
- C. Atrial flutter
- D. Supraventricular tachycardia
Correct Answer: B
Rationale: A regular rate >100 with normal P waves, QRS complexes, and PR interval indicates sinus tachycardia, a common response to stress, fever, or hypoxia.
The nurse is caring for an infant admitted from the delivery room. Which finding should be reported?
- A. Acyanosis
- B. Acrocyanosis
- C. Halequin sign
- D. Absent femoral pulses
Correct Answer: D
Rationale: Absent femoral pulses suggest coarctation of the aorta, a critical condition.
A client in labor has been given epidural anesthesia with Marcaine (bupivacaine). To reverse the hypotension associated with epidural anesthesia, the nurse should have which medication available?
- A. Narcan (naloxone)
- B. Dobutrex (dobutamine)
- C. Romazicon (flumazenil)
- D. Adrenalin (epinephrine)
Correct Answer: D
Rationale: Epinephrine is used to treat hypotension from epidural anesthesia by increasing blood pressure through vasoconstriction and cardiac stimulation.