Nokea
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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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.
What does the nurse explain that a ventricular septal defect will allow?
- A. Blood to shunt left to right, causing increased pulmonary flow and no cyanosis
- B. Blood to shunt right to left, causing decreased pulmonary flow and cyanosis
- C. No shunting because of high pressure in the left ventricle
- D. Increased pressure in the left atrium, impeding circulation of oxygenated blood in the circulating volume
Correct Answer: A
Rationale: Pulmonary blood flow is increased when a ventricular septal defect exists. The blood shifts from left to right because of the higher pressure in the left ventricle. This particular shift does not cause cyanosis.
A young female client with seven children is having frequent morning headaches, dizziness, and blurred vision. Her blood pressure (BP) is 168/104 mmHg. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV medication, which intervention is most important for the nurse to implement?
- A. Measure urine output hourly to assess for rental perfusion
- B. Request a prescription for pain medication
- C. Use an automated BP machine to monitor for hypotension
- D. Provide a quiet environment with low lighting
Correct Answer: C
Rationale: Monitoring blood pressure is crucial after administering an antihypertensive to ensure the client does not become hypotensive.
Which are the most serious complications for a child with Kawasaki disease? Select all that apply.
- A. Coronary thrombosis
- B. Hypocoagulability
- C. Decreased sedimentation time (ESR)
- D. Coronary stenosis
Correct Answer: A
Rationale: The most serious complications of Kawasaki disease involve the coronary arteries, including thrombosis, stenosis, and aneurysms, which can lead to significant cardiac issues.
Regarding resuscitation of a three-year old with asystole:
- A. Hypoxia is the commonest cause
- B. It commonly leads to ventricular fibrillation
- C. Intracardiac adrenaline is an absolute indication
- D. IV calcium gluconate is the first line of therapy
Correct Answer: A
Rationale: Hypoxia is the most common cause of asystole in children, emphasizing the importance of oxygenation during resuscitation.