Nokea
The nurse in the holding area of the operating room is assessing the client prior to surgery. Which information warrants immediate intervention by the nurse?
- A. The client is able to mark the correct site for the surgery.
- B. The client can only tell the nurse about the surgery in lay terms.
- C. The client is allergic to iodine and does not have an allergy bracelet.
- D. The client has signed a consent form for surgery and anesthesia.
Correct Answer: C
Rationale: Missing an allergy bracelet for iodine risks exposure during surgery, requiring immediate intervention. Site marking, lay terms, and consent are appropriate.
You may also like to solve these questions
The client has had an anaphylactic reaction to insect venom, a bee sting. Which discharge instruction should the nurse discuss with the client?
- A. Take a corticosteroid dose pack when stung by a bee.
- B. Take antihistamines prior to outdoor activities.
- C. Use a cromolyn sodium (Intal) inhaler prophylactically.
- D. Carry a bee sting kit, especially when going outside.
Correct Answer: D
Rationale: Carrying a bee sting kit (EpiPen) is critical for managing future anaphylaxis. Steroids, antihistamines, and cromolyn are less effective prophylactically.
The client diagnosed with AIDS is complaining of a sore mouth and tongue. When the nurse assesses the buccal mucosa, the nurse notes white, patchy lesions covering the hard and soft palates and the right inner cheek. Which interventions should the nurse implement?
- A. Teach the client to brush the teeth and patchy area with a soft-bristle toothbrush.
- B. Notify the HCP for an order for an antifungal swish-and-swallow medication.
- C. Have the client gargle with an antiseptic-based mouthwash several times a day.
- D. Determine what types of food the client has been eating for the last 24 hours.
Correct Answer: B
Rationale: White, patchy lesions suggest oral candidiasis, common in AIDS, requiring antifungal medication. Brushing may worsen lesions, antiseptic mouthwash is insufficient, and diet history is secondary.
The nurse writes the client problem of 'altered sexual functioning' for a male client diagnosed with multiple sclerosis (MS). Which intervention should be implemented?
- A. Encourage the couple to explore alternative ways of maintaining intimacy.
- B. Make an appointment with a psychotherapist to counsel the couple.
- C. Explain daily exercise will help increase libido and sexual arousal.
- D. Discuss the importance of keeping physically calm during sexual intercourse.
Correct Answer: A
Rationale: Exploring alternative intimacy methods addresses MS-related sexual dysfunction holistically. Psychotherapy is secondary, exercise may not improve libido, and physical calm is vague.
The client is experiencing an anaphylactic reaction to bee venom. Which interventions should the nurse implement? List in order of priority.
- A. Establish a patent airway.
- B. Administer epinephrine, an adrenergic agonist, IVP.
- C. Start an IV with 0.9% saline.
- D. Teach the client to carry an EpiPen when outside.
- E. Administer diphenhydramine (Benadryl), an antihistamine, IVP.
Correct Answer: A,B,C,E,D
Rationale: Priority: 1) Airway (ABCs); 2) Epinephrine (reverse anaphylaxis); 3) IV fluids (support hemodynamics); 4) Diphenhydramine (reduce histamine effects); 5) EpiPen teaching (prevention).
The 20-year-old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications?
- A. Are you sexually active, and, if so, are you using birth control?
- B. Have you discussed taking these drugs with your parents?
- C. Which arm do you prefer to have an IV in for four (4) days?
- D. Have you signed an informed consent for investigational drugs?
Correct Answer: A
Rationale: Immunosuppressants are teratogenic, making contraception critical. Parental discussion, IV preference, and investigational consent are less relevant.