Nokea
The client has a latex allergy. What should the nurse teach the client to do before having surgery at a free-standing surgery center? Select all that apply.
- A. Determine that there will be a latex-safe environment for surgery.
- B. Report symptoms experienced with the latex allergy (e.g., rhinitis, conjunctivitis, flushing).
- C. Notify the health care providers at the surgery center.
- D. Wear a stainless steel medical alert bracelet into the surgical suite.
- E. Ask to have the surgery at a hospital.
Correct Answer: A,B,C
Rationale: Treatment and diagnostic evaluation must be done in a latex-safe environment. Signs/symptoms may be mild to anaphylaxis. Clients with latex allergy are advised to notify their health care providers and to wear a medical ID; however, all metal and jewelry must be removed prior to surgery as they could conduct an electrical current.
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A client returned home from an overseas tour of duty and tells the nurse he is always tired. He has a temperature of 99.5°F (37.5°C). His skin is dark bronze, and his urine has a dark color. His hemoglobin level is 9 g/dL; his hematocrit is 49, and red blood cells are 2.75 million/µL. What should the nurse do first?
- A. Initiate an intake and output record.
- B. Place the client on bed rest.
- C. Place the client on contact isolation.
- D. Keep the client out of sunlight.
Correct Answer: B
Rationale: The client's symptoms (fatigue, bronze skin, dark urine, low hemoglobin, and RBC count) suggest hemolytic anemia, possibly due to an infectious or toxic exposure overseas. Placing the client on bed rest is the priority to reduce oxygen demand and prevent further hemolysis while diagnostic evaluation proceeds. Intake/output monitoring, isolation, and sunlight avoidance are not immediate priorities.
Which of the following should the nurse assess when completing the history and physical examination of a client diagnosed with osteoarthritis?
- A. Anemia.
- B. Osteoporosis.
- C. Weight loss.
- D. Local joint pain.
Correct Answer: D
Rationale: Local joint pain is a primary symptom of osteoarthritis, resulting from cartilage degeneration.
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
- A. Compress the nares.
- B. Tilt the head back.
- C. Give the client tissues to collect the fluid.
- D. Administer an antihistamine for postnasal drip.
Correct Answer: C
Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. The nurse should:
- A. Count the rate to be sure that ventilations are deep enough to be sufficient.
- B. Notify the physician of the client's breathing pattern.
- C. Increase the rate of ventilations.
- D. Increase the tidal volume on the ventilator.
Correct Answer: B
Rationale: Cluster breathing, a sign of neurological deterioration, requires immediate physician notification for evaluation and possible intervention. Adjusting ventilator settings without medical orders is inappropriate, and simply counting the rate does not address the underlying issue.
What should the nurse monitor in a client receiving baclofen?
- A. Blood pressure.
- B. Spasticity levels.
- C. Blood glucose.
- D. Respiratory rate.
Correct Answer: B
Rationale: Spasticity levels are monitored to evaluate the effectiveness of baclofen in reducing muscle spasticity.