Nokea
The nurse is assessing a client recovering from anesthesia. Which of the following is an early indicator of hypoxemia?
- A. Somnolence.
- B. Restlessness.
- C. Chills.
- D. Urgency.
Correct Answer: B
Rationale: Restlessness is an early sign of hypoxemia, as the brain responds to low oxygen levels with agitation before more severe symptoms like somnolence or cyanosis appear.
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Multiple clients have been brought to the emergency department after being struck by lightning during a severe thunderstorm. Which of the following clients should the nurse prioritize? The client who?
- A. reports numbness and tingling in all their extremities.
- B. has paralysis on both lower extremities.
- C. is confused and cannot remember their name or why they are in the emergency department.
- D. experienced a massive electrical current discharge to their body.
Correct Answer: B
Rationale: Paralysis in both lower extremities indicates potential spinal cord injury or severe neurological damage, requiring immediate prioritization. Numbness and tingling (A) suggest peripheral nerve issues, confusion (C) may indicate concussion or hypoxia, and massive discharge (D) lacks specific clinical urgency without symptoms.
When completing the Preoperative Checklist on the nursing unit, the nurse discovers an allergy that the client has not reported. What should the nurse do first?
- A. Administer the prescribed pre-anesthetic medication.
- B. Note this new allergy prominently at the front of the chart.
- C. Contact the scrub nurse in the operating room.
- D. Inform the nurse anesthetist.
Correct Answer: D
Rationale: A newly discovered allergy must be communicated to the nurse anesthetist first, as it may affect anesthesia choices and prevent allergic reactions during surgery.
The nurse is assessing a client's activity tolerance by having the client walk on a treadmill for 5 minutes. Which of the following indicates an abnormal response?
- A. Pulse rate increased by 20 beats per minute (bpm) immediately after the activity.
- B. Respiratory rate decreased by 5 breaths/minute.
- C. Diastolic blood pressure increased by 7 mm Hg.
- D. Pulse rate within 6 bpm of resting pulse after 3 minutes of rest.
Correct Answer: B
Rationale: A decrease in respiratory rate after exercise is abnormal, as physical activity typically increases respiratory demand to meet oxygen needs. A pulse increase of 20 bpm, a slight rise in diastolic blood pressure, and a near-return to resting pulse after 3 minutes are normal responses to moderate exercise.
The client is ready for discharge after surgery for a deviated septum. Which of the following discharge instructions would be appropriate?
- A. Avoid activities that elicit Valsalva's maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding Valsalva's maneuver (e.g., straining, heavy lifting) prevents increased pressure that could cause bleeding or disrupt the surgical site.
The nurse is applying a hand mitt restraint for a client with pruritis (see fi gure). The nurse should first:
- A. Verify the physician order to use the restraint.
- B. Secure the mitt with ties around the wrist tied to the bed frame.
- C. Place a folded pillow under the wrist.
- D. Place the mitt on top of the hand.
Correct Answer: A
Rationale: Before using any restraints, the nurse must verify that a physician has written an order for the restraint. The mitt does not need to be secured with ties. The client can move the hand as needed. It is not necessary to place a pillow under the wrist. The nurse should place the mitt on the palmer surface of the hand.