Nokea
The client has returned to the surgery unit from the Post Anesthesia Care Unit (PACU). The client's respirations are rapid and shallow, the pulse is 120, and the blood pressure is 88/52. The client's level of consciousness is deteriorating. The nurse should do which of the following first?
- A. Call the Post Anesthesia Care Unit (PACU).
- B. Call the primary care physician.
- C. Call the respiratory therapist.
- D. Call the Rapid Response Team.
Correct Answer: D
Rationale: Rapid, shallow respirations, tachycardia, hypotension, and deteriorating consciousness suggest shock or respiratory distress. Calling the Rapid Response Team ensures immediate intervention.
You may also like to solve these questions
The nurse is preparing to administer an intramuscular (IM) injection into the client's vastus lateralis. The nurse is correct in identifying the landmark by
- A. palpating to find greater trochanter and knee joints; divide the vertical distance between these two landmarks into thirds; inject into the middle third.
- B. locating the acromion process; inject only into the upper third of muscle that begins about two fingerbreadths below the acromion.
- C. locating the greater trochanter, iliac tubercle, and iliac crest; places palm over the greater trochanter, over iliac tubercle, along the ileum; inject into center of V formed by the fingers.
- D. displacing the skin by pulling the skin down or to one side about 1 inch with the non-dominant hand before administering the injection.
Correct Answer: A
Rationale: The vastus lateralis is correctly located by dividing the thigh into thirds between the greater trochanter and knee, with the middle third being the injection site.
Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?
- A. Sodium phosphate.
- B. Calcium gluconate.
- C. Echothiophate iodide.
- D. Sodium bicarbonate.
Correct Answer: B
Rationale: Calcium gluconate is used to treat tetany by correcting hypocalcemia, which causes muscle spasms and tingling.
A client is to have a cystoscopy to rule out cancer of the bladder. Which of the following indicate that the client has developed a complication after the cystoscopy?
- A. Dizziness.
- B. 2. skills.
- C. Pink-tinged urine.
- D. Bladder spasms.
Correct Answer: D
Rationale: Bladder spasms post-cystoscopy indicate a complication, often due to irritation or trauma to the bladder lining, requiring medical attention. Pink-tinged urine is expected, and dizziness may relate to other causes.
The nurse is reviewing a client's preoperative checklist and notes the client has not voided in the last 6 hours. The nurse should:
- A. Insert a urinary catheter.
- B. Encourage the client to void before transport.
- C. Notify the anesthesiologist.
- D. Document the finding and proceed.
Correct Answer: B
Rationale: Encouraging the client to void prevents bladder distention during surgery and reduces the need for catheterization, which carries infection risks.
The nurse develops a plan of care for a client in the initial postoperative period following a lumbar laminectomy. Which of the following activities is contraindicated?
- A. Assisting with her daily hygiene activities.
- B. Lying flat in bed.
- C. Walking in the hall.
- D. Sitting all afternoon in her room.
Correct Answer: D
Rationale: Prolonged sitting stresses the surgical site and is contraindicated post-laminectomy.