Nokea
As a nurse preceptor, you are in the operating room with a student nurse. The client has received general anesthesia. The student nurse says, 'Oh no, the general anesthesia is not working. The client is shaking and moving.' How should you respond to this student nurse?
- A. The client is having anesthesia awareness which is not good.'
- B. This often happens during stage 2 of general anesthesia.'
- C. The client needs more general anesthesia.'
- D. The client is having a seizure.'
Correct Answer: B
Rationale: Shaking and moving during stage 2 (excitement phase) of general anesthesia is normal due to loss of inhibitory control before deeper anesthesia is achieved.
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Place these steps of the medication reconciliation process in the correct sequential order from # 1 to # 5. Do NOT include steps that are not part of the medication reconciliation process. 1: Compile a list of newly prescribed medications and other preparations 2: Compile a list of current medications and other preparations 3: Compile a list of only current vitamins, over the counter medications, herbal remedies, nutritional and dietary supplements 4: Compare the two lists and make note of any discrepancies and inconsistencies 5: Employ critical thinking and professional judgments during the comparisons of the two lists 6: Communicate and document the new list of medications to the appropriate healthcare providers
- A. 3,2,1,4,6
- B. 2,1,4,5,6
- C. 1,2,3,5,4
- D. 4,1,3,2,6
Correct Answer: B
Rationale: The medication reconciliation process involves: 1) Compiling current medications, 2) Compiling new medications, 3) Comparing lists for discrepancies, 4) Using critical thinking, 5) Communicating the reconciled list.
A primary health care provider has written a prescription for a client diagnosed with diabetic gastroparesis to receive metoclopramide four times a day. The nurse schedules this medication to be given at which times?
- A. With each meal and at bedtime
- B. Thirty minutes before meals and at bedtime
- C. One hour after each meal and at bedtime
- D. Every 6 hours spaced evenly around the clock
Correct Answer: B
Rationale: Metoclopramide stimulates the motility of the upper gastrointestinal tract and is used to treat gastroparesis (nausea, vomiting, and persistent fullness after meals). The client should be taught to take this medication 30 minutes before meals and at bedtime. The before-meals administration allows the medication time to begin working before the client consumes food that requires digestion. The other options suggest information that is incorrect.
A client being mechanically ventilated after experiencing a fat embolus is visibly anxious. Which action should the nurse take?
- A. Remain with the client and provide reassurance.
- B. Ask a family member to stay with the client at all times.
- C. Encourage the client to sleep until arterial blood gas results improve.
- D. Ask the primary health care provider to write a prescription for an antianxiety medication.
Correct Answer: A
Rationale: The nurse always speaks to the client calmly and provides reassurance to the anxious client. Family members are also stressed because of the severity of the situation; therefore, it is not beneficial to ask the family to take on the burden of remaining with the client at all times. Encouraging the client to sleep will not assist in relieving the client's anxiety. Antianxiety medications are used only if necessary and if other interventions fail to relieve the client's anxiety.
Before discharge from the hospital after a myocardial infarction, a client is taught to exercise by gradually increasing the distance walked. Which vital sign should the nurse teach the client to monitor to determine whether to increase or decrease the exercise level?
- A. Pulse rate.
- B. Blood pressure.
- C. Body temperature.
- D. Respiratory rate.
Correct Answer: A
Rationale: Monitoring pulse rate helps determine if the exercise level is appropriate, as an excessively high rate indicates overexertion.
A client with chronic renal failure is receiving epoetin alfa (Epogen). The nurse should monitor the client for which of the following adverse effects?
- A. Hypertension.
- B. Hypoglycemia.
- C. Bradycardia.
- D. Hypokalemia.
Correct Answer: A
Rationale: Epoetin alfa can cause hypertension due to increased red blood cell production and blood viscosity, requiring close monitoring.