Nokea
The nurse is caring for a client who is scheduled for surgery in the morning. The client reports drinking a glass of water at midnight. What should the nurse do?
- A. Notify the anesthesiologist
- B. Document the intake in the medical record
- C. Cancel the surgery
- D. Instruct the client to fast until the surgery
Correct Answer: A
Rationale: The correct answer is to notify the anesthesiologist. When a client reports drinking water close to the time of surgery, it is important to inform the anesthesiologist as it can impact the administration of anesthesia. The anesthesiologist needs this information to make decisions regarding anesthesia administration. Documenting the intake in the medical record is important for documentation purposes, but the immediate action needed is to inform the anesthesiologist. Canceling the surgery is not necessary based solely on the intake of water; the anesthesiologist will determine the appropriate course of action. Instructing the client to fast until the surgery may not be appropriate without consulting the anesthesiologist first, as the situation needs to be assessed by the anesthesia team.
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The nurse is assessing a client with hyperkalemia. Which finding is consistent with this electrolyte imbalance?
- A. Muscle weakness
- B. Decreased deep tendon reflexes
- C. Constipation
- D. Hypotension
Correct Answer: A
Rationale: Muscle weakness is a common finding in clients with hyperkalemia. Hyperkalemia can lead to muscle weakness due to the effect of high potassium levels on muscle function. Decreased deep tendon reflexes (Choice B) are not typically associated with hyperkalemia; instead, hyperreflexia or increased reflexes may be observed. Constipation (Choice C) is not a common symptom of hyperkalemia. Hypotension (Choice D) is also not a typical finding in hyperkalemia; instead, hypertension or normal blood pressure may be present.
The nurse is monitoring a client with an IV infusion in the left antecubital fossa. The site is warm, red, and without swelling. What conclusion should the nurse draw from these findings?
- A. The IV fluids are infusing into the subcutaneous tissues
- B. The infusion pump is functioning properly
- C. The insertion date should be verified and the IV discontinued
- D. The site is inflamed and should be reported
Correct Answer: B
Rationale: The correct answer is B. Warmth and redness at the IV site without swelling indicate a localized reaction, which is common and does not necessarily indicate infiltration of IV fluids into the subcutaneous tissues. The absence of swelling suggests that the IV is correctly placed. Therefore, the nurse should conclude that the infusion pump is functioning properly. Choice A is incorrect as warmth and redness alone do not indicate subcutaneous infiltration. Choice C is incorrect as discontinuing the IV solely based on warmth and redness without swelling is not necessary. Choice D is incorrect as the absence of swelling signifies a localized reaction rather than inflammation requiring immediate reporting.
The nurse is caring for a client postoperatively following a thyroidectomy. Which assessment finding should be reported to the healthcare provider immediately?
- A. Hoarseness of the voice.
- B. Slight swelling at the incision site.
- C. Tingling around the mouth.
- D. Mild fever.
Correct Answer: C
Rationale: Tingling around the mouth should be reported to the healthcare provider immediately as it may indicate hypocalcemia, a potential complication after thyroidectomy. Hoarseness of the voice is common postoperatively due to surgical manipulation, slight swelling at the incision site is a normal response, and a mild fever can be expected after surgery. However, tingling around the mouth suggests a potential calcium imbalance, which requires prompt attention to prevent serious complications.
Based on the Nursing diagnosis of 'Potential for infection related to second and third degree burns,' which intervention has the highest priority?
- A. Application of topical antibacterial cream
- B. Use of careful hand washing technique
- C. Administration of plasma expanders
- D. Limiting visitors to the burned client
Correct Answer: B
Rationale: The highest priority intervention in this scenario is B, the use of careful hand washing technique. Proper hand hygiene is essential in preventing infection, especially in individuals with compromised skin integrity like those with burns. By practicing careful hand washing, healthcare providers reduce the risk of introducing harmful pathogens to the burn wound, thus lowering the chances of infections. Choice A, application of topical antibacterial cream, is important but should follow ensuring proper hand hygiene. Choice C, administration of plasma expanders, is not directly associated with preventing burn-related infections. Choice D, limiting visitors, is significant for infection control, but ensuring proper hand hygiene outweighs this intervention in terms of priority.
When teaching a group of school-aged children how to reduce the risk for Lyme disease, which instruction should the camp nurse include?
- A. Wash hands frequently.
- B. Avoid drinking lake water.
- C. Do not share personal products.
- D. Wear long sleeves and pants.
Correct Answer: D
Rationale: The correct answer is 'Wear long sleeves and pants.' This instruction is crucial in reducing the risk of Lyme disease because it helps minimize exposure to ticks that carry the disease. Ticks are commonly found in grassy and wooded areas, so covering up with long sleeves and pants can act as a physical barrier and prevent ticks from attaching to the skin. Choices A, B, and C are not directly related to preventing Lyme disease. Washing hands frequently is important for general hygiene but not specifically for preventing tick bites. Avoiding drinking lake water is more about preventing waterborne illnesses rather than Lyme disease. Not sharing personal products is important for preventing the spread of infections but is not directly related to Lyme disease prevention.