Nokea
The nurse in the postanesthesia care unit notes that one of the client's pupils is larger than the other. The nurse should:
- A. Rate the client on the Glasgow Coma Scale.
- B. Administer oxygen.
- C. Check the client's baseline data.
- D. Call the surgeon.
Correct Answer: D
Rationale: Unequal pupils post-surgery suggest a neurological issue, such as increased intracranial pressure or stroke. Calling the surgeon ensures prompt evaluation and intervention.
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While talking to her husband, who is caring for their children, a 52-year-old client slams the phone down. She begins to cry and states that she is feeling guilty for being hospitalized. Which of the following interventions will best support the client emotionally?
- A. Call the physician and ask for a psychiatry consultation.
- B. Call the physician and request an antidepressant medication.
- C. Sit with the client and help her acknowledge and discuss her feelings.
- D. Sit with the client and encourage her to see the good side of the situation.
Correct Answer: C
Rationale: Sitting with the client and helping her discuss her feelings validates her emotions and supports her in processing guilt, providing emotional relief.
The nurse is preparing a preoperative teaching plan for a client who is undergoing a bilateral breast reduction. Which aspect of the plan is the priority?
- A. Reduction of risk potential.
- B. Physiologic adaptation.
- C. Psychosocial integrity.
- D. Health promotion and maintenance.
Correct Answer: C
Rationale: Psychosocial integrity is the priority for breast reduction surgery, as it addresses body image, self-esteem, and emotional adjustment, which are significant concerns for clients undergoing this procedure.
A client's serum ammonia level is elevated, and the physician orders 30 mL of lactulose (Cephulac). Which of the following is an adverse effect of this drug?
- A. Increased urine output.
- B. Improved level of consciousness.
- C. Increased bowel movements.
- D. Nausea and vomiting.
Correct Answer: C
Rationale: Lactulose promotes bowel movements (C) to excrete ammonia, a common adverse effect. Urine output (A) and consciousness (B) are not adverse effects. Nausea (D) is less common.
A short time after cataract surgery, the client complains of nausea. The nurse should first:
- A. Instruct the client to take a few deep breaths until the nausea subsides.
- B. Explain that this is a common feeling that will pass quickly.
- C. Tell the client to call the nurse promptly if vomiting occurs.
- D. Administer an antiemetic, as ordered.
Correct Answer: D
Rationale: Nausea after cataract surgery can indicate increased intraocular pressure or other complications. Administering an antiemetic as ordered is the priority to prevent vomiting, which could increase intraocular pressure and cause complications.
A client who had received 25 mL of packed red blood cells (PRBCs) has low back pain and pruritus. After stopping the infusion, the nurse should take what action next?
- A. Administer prescribed antihistamine and aspirin.
- B. Collect blood and urine samples and send to the lab.
- C. Administer prescribed diuretics.
- D. Administer prescribed vasopressors.
Correct Answer: B
Rationale: Low back pain and pruritus after 25 mL of PRBCs suggest a transfusion reaction, likely hemolytic or allergic. After stopping the infusion, the nurse should collect blood and urine samples to assess for hemolysis (e.g., free hemoglobin in plasma or urine). Antihistamines may be administered later for allergic symptoms, but lab samples are the priority. Diuretics and vasopressors are not indicated.