Nokea
The client is to receive regional anesthesia (spinal anesthesia) during surgery. Which of the following is an important nursing implication regarding this anesthesia?
- A. The client should be adequately hydrated in order to prevent hypotension after anesthesia is established.
- B. To decrease the risk of aspiration, the client must be NPO at least 12 hours prior to the initiation of the anesthesia.
- C. Assess the client for any allergies to Betadine or iodine preparations.
- D. Determine the specific gravity of the urine and prepare the client for insertion of a central line.
Correct Answer: A
Rationale: Spinal anesthesia causes vasodilation, risking hypotension; hydration is critical. Options B, C, and D are excessive or unrelated.
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The daughter of a 70-year-old patient with cancer asks the nurse, 'Do you believe in euthanasia?' Which of the following responses by the nurse is BEST?
- A. I think that each person has to decide this issue for herself.
- B. My religion is opposed to euthanasia.
- C. What are your thoughts about euthanasia?
- D. Did you see the TV program about euthanasia last night?
Correct Answer: C
Rationale: open-ended question, allows client to verbalize
A client received six units of regular insulin three hours ago.
- A. Which observation would be most concerning for a client who received six units of regular insulin three hours ago?
- B. Kussmaul respirations and diaphoresis.
- C. Anorexia and lethargy.
- D. Diaphoresis and trembling.
- E. Headache and polyuria.
Correct Answer: C
Rationale: Regular insulin peaks in 2-4 hours, and diaphoresis and trembling are classic signs of hypoglycemia, a potentially life-threatening complication requiring immediate intervention (e.g., administering skim milk). Kussmaul respirations indicate hyperglycemia, while anorexia, lethargy, headache, and polyuria are not specific to hypoglycemia.
A client has a right total hip replacement. The client returns from surgery with an IV of 0.45% NaCl infusing into the left forearm at 100 cc/h. It is MOST important for the nurse to take which of the following actions?
- A. Massage the client's legs to increase circulation.
- B. Elevate the knee gatch to reduce stress on the suture line.
- C. Apply thigh-high TED hose to promote venous return.
- D. Decrease fluid intake to 1,200 cc to prevent circulatory overload.
Correct Answer: C
Rationale: use of antiembolic hose and/or sequential compression devices decreases venous stasis and reduces risk of thrombus formation
The nurse is assessing a client with suspected appendicitis. Which of the following findings would the nurse expect to observe?
- A. Pain relieved by pressure at McBurney's point.
- B. Rebound tenderness at McBurney's point.
- C. Pain in the left lower quadrant.
- D. Decreased bowel sounds in all quadrants.
Correct Answer: B
Rationale: rebound tenderness at McBurney's point is a classic sign of appendicitis
After receiving report, which of the following patients should the nurse see FIRST?
- A. A patient in sickle-cell crisis with an infiltrated IV.
- B. A patient with leukemia who has received one-half unit of packed cells.
- C. A patient scheduled for a bronchoscopy.
- D. A patient complaining of a leaky colostomy bag.
Correct Answer: A
Rationale: IV fluids are critical to reduce clotting and pain