Nokea
Because of the rapid elimination of volatile liquids used for general anesthesia, what should the nurse anticipate the patient will need early in the anesthesia recovery period?
- A. Warm blankets
- B. Analgesic medication
- C. Observation for respiratory depression
- D. Airway protection in anticipation of vomiting
Correct Answer: C
Rationale: Rapid elimination can lead to respiratory depression, necessitating close observation.
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In developing a discharge plan for a patient requiring home-care services, what is important to assess?
- A. Patient’s nursing diagnosis
- B. Availability of needed community services
- C. Patient’s functional abilities
- D. Patient’s family dynamics
Correct Answer: B
Rationale: Ensuring access to necessary community services is vital for successful home care.
What is the definition of blindness in terms of the best corrected visual acuity (BCVA)?
- A. Less than 20/200 even with correction
- B. Between 20/70 and 20/200 in the better eye with glasses
- C. 20/400 or greater with no light perception
- D. 20/40 in at least one eye with correction
Correct Answer: A
Rationale: Blindness is legally defined as BCVA less than 20/200 in the better eye with correction.
Brendan has chronic obstructive pulmonary disease, causing a constant state of respiratory acidosis. He has a history of chronic trimethoprim and NSAID use, leading to hyperkalemia. Which of the following are associated with hyperkalemia?
- A. Irritability,circumoral paresthesia muscle spasms tetany abdominal pain laryngospasm and prolonged QT intervals.
- B. Muscle cramps malaise diminished deep tendon reflexes anorexia constipation palpitations and rhabdomyolysis.
- C. Cardiac arrhythmia nausea vomiting constipation dehydration kidney stones muscle weakness and sinus arrest.
- D. Weakness dizziness abdominal distention nausea vomiting diarrhea palpitations and cardiac arrhythmias.
Correct Answer: C
Rationale: The correct answer is Cardiac arrhythmia, nausea, vomiting, constipation, dehydration, kidney stones, muscle weakness, and sinus arrest (C). Hyperkalemia affects cardiac function, leading to arrhythmias and potentially life-threatening conditions like sinus arrest. Gastrointestinal symptoms such as nausea, vomiting, and constipation are also common.
A client with lung cancer has received oxycodone 10 mg orally for pain. When the student nurse assesses the client, which finding should you instruct the student to report immediately?
- A. Respiratory rate of 8 to 10 per minute
- B. Pain level decreased from 6/10 to 2/10
- C. Client requests room door be closed
- D. Heart rate 90-100 per minute
Correct Answer: A
Rationale: Oxycodone can depress respiration; a respiratory rate of 8-10 per minute is abnormally low and requires immediate attention to prevent respiratory failure.
A client presents to the emergency department with an acute myocardial infarction (MI) at 1500 (3:00 PM). The facility has 24-hour catheterization laboratory capabilities. To meet The Joint Commission's Core Measures set, by what time should the client have a percutaneous coronary intervention performed?
- A. 1530 (3:30 PM)
- B. 1600 (4:00 PM)
- C. 1630 (4:30 PM)
- D. 1700 (5:00 PM)
Correct Answer: C
Rationale: The correct answer is C: 1630 (4:30 PM). The rationale is as follows:
1. The standard guideline for performing percutaneous coronary intervention (PCI) in acute MI is within 90 minutes of arrival at the hospital.
2. The client arrived at 1500 (3:00 PM), so adding 90 minutes to this time gives us 1630 (4:30 PM).
3. This timing aligns with The Joint Commission's Core Measures for timely PCI in acute MI cases.
4. Therefore, the correct time for the client to have PCI performed is 1630 (4:30 PM).
In summary, choices A, B, and D are incorrect because they do not align with the 90-minute guideline for performing PCI in acute MI cases, as mandated by The Joint Commission's Core Measures.