The nurse is completing the preoperative assessment of a client who is scheduled for a laparoscopic cholecystectomy under general anesthesia. Which finding warrants notification of the healthcare provider prior to proceeding with the scheduled procedure?
- A. Light yellow coloring of the client's skin and eyes
- B. The client's blood pressure reading is 184/88 mm Hg.
- C. The client vomits 20 ml of clear yellowish fluid
- D. The IV insertion site is red, swollen, and leaking IV fluid
Correct Answer: B
Rationale: High blood pressure increases the risk of complications during surgery and needs to be addressed before proceeding.
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What does the nurse need to assess first when caring for a child with a suspected myocardial infarction?
- A. Blood pressure and heart rate
- B. Chest pain and anxiety levels
- C. Oxygen saturation and respiratory rate
- D. Electrocardiogram and heart sounds
Correct Answer: D
Rationale: The first priority in a suspected myocardial infarction is to assess the heart's electrical activity using an electrocardiogram and listen to heart sounds for any abnormality such as murmurs.
Factors triggering renin stimulation:
- A. Hyponatraemia
- B. ACTH
- C. Hypovolaemia
- D. ANP
Correct Answer: C
Rationale: Hypovolaemia
Common reasons for doing a BMT in children are:
- A. SCID (severe combined immunodeficiency)
- B. Acute lymphoblastic leukemia
- C. CML
- D. Gaucher's disease
Correct Answer: A
Rationale: The correct answer is A because SCID is a primary indication for bone marrow transplant (BMT) in children. The other options (b-e) are also indications but less common.
After a computer tomography (CT) scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?
- A. Call respiratory therapy to give a breathing treatment
- B. Send another nurse for an emergency tracheotomy set
- C. Prepare a dose of epinephrine (Adrenalin)
- D. Review the client's complete list of allergies
Correct Answer: C
Rationale: Shortness of breath and itching are signs of an allergic reaction to the contrast medium, and epinephrine is the first-line treatment for anaphylaxis.
The following drugs induce hepatic enzymes:
- A. Rifampicin
- B. Phenobarbitone
- C. Cimetidine
- D. Erythromycin
Correct Answer: A
Rationale: Rifampicin is known to induce hepatic enzymes, which can increase the metabolism of other drugs and reduce their efficacy.