Nokea
The nurse anticipates that the client who has received epidural anesthesia is at decreased risk for a spinal headache because:
- A. A 17G needle is used.
- B. A subarachnoid injection is made.
- C. A noncutting needle is used.
- D. A faster onset occurs.
Correct Answer: C
Rationale: Epidural anesthesia uses a noncutting needle, reducing dural puncture risk and thus lowering the incidence of spinal headache compared to spinal anesthesia.
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A client is scheduled for an ileostomy. Which of the following interventions would be most helpful in preparing the client psychologically for the surgery?
- A. Include family members in preoperative teaching sessions.
- B. Encourage the client to ask questions about managing an ileostomy.
- C. Provide a brief, thorough explanation of all preoperative and postoperative procedures.
- D. Invite a member of the ostomy association to visit the client.
Correct Answer: B
Rationale: Encouraging the client to ask questions about managing an ileostomy promotes active engagement, addresses specific concerns, and supports psychological preparation. Including family, providing explanations, or arranging visits are helpful but less directly empower the client's coping process. CN: Psychosocial adaptation; CL: Synthesize
What is the nurse's priority for a client with an altered level of consciousness?
- A. Assess airway.
- B. Check reflexes.
- C. Monitor urine output.
- D. Perform a pain assessment.
Correct Answer: A
Rationale: Assessing the airway is the priority to ensure adequate oxygenation in a client with altered consciousness.
A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, 'Why can't I stop talking about these things? I know those days are gone forever.' Which of the following responses by the nurse conveys the best understanding of the client's behavior?
- A. Be patient. It takes time to adjust to such a massive loss.'
- B. I will be sure to tell the team that reviewing the past is a form of denial. We have to help you focus on today.'
- C. Reviewing your losses is a way to help you work through your grief and loss.'
- D. It's a simple escape mechanism to go back and live again in happier times.'
Correct Answer: C
Rationale: Reflecting on past activities is part of grieving, helping the client process the loss of function.
Guaifenesin (Robitussin) 300 mg four times a day has been ordered as an expectorant. The dosage strength of the liquid is 200 mg/5 mL. How many milliliters should the nurse administer for each dose?
Correct Answer: 7.5 mL
Rationale: To calculate the dose: 300 mg ÷ 200 mg/5 mL = 1.5 × 5 mL = 7.5 mL per dose.
A female client diagnosed with lung cancer is to have a left lower lobectomy. Which of the following increase the client's risk of developing postoperative pulmonary complications?
- A. Height is 5 feet, 7 inches and weight is 110 lb.
- B. The client tends to keep her real feelings to herself.
- C. 8.88 stimulates and can climb one flight of stairs without dyspnea.
- D. The client is 58 years of age.
Correct Answer: A
Rationale: Low body weight (5'7€, 110 lb) indicates malnutrition, increasing the risk of postoperative pulmonary complications due to weakened respiratory muscles. Emotional suppression, good exercise tolerance, and age 58 are less directly related.