Nokea
The nurse is encouraging the client to cough and deep breathe after cardiac surgery. The nurse ensures that which item is available to maximize the effectiveness of this procedure?
- A. Nebulizer
- B. Ambu bag
- C. Suction equipment
- D. Incisional splinting pillow
Correct Answer: D
Rationale: The use of an incisional splint such as a 'cough pillow' can ease discomfort during coughing and deep breathing. The client who is comfortable will do more effective deep breathing and coughing exercises. Use of an incentive spirometer is also indicated. Options 1, 2, and 3 will not encourage the client to cough and deep breathe.
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Which nursing assessment question should be asked to help determine the client's risk for developing malignant hyperthermia in the perioperative period?
- A. Have you ever had heat exhaustion or heat stroke?
- B. What is the normal range for your body temperature?
- C. Do you or any of your family members have frequent infections?
- D. Do you or any of your family members have problems with general anesthesia?
Correct Answer: D
Rationale: Malignant hyperthermia is a genetic disorder in which a combination of anesthetic agents (the muscle relaxant succinylcholine and inhalation agents such as halothanes) triggers uncontrolled skeletal muscle contractions that can quickly lead to a potentially fatal hyperthermia. Questioning the client about the family history of general anesthesia problems may reveal this as a risk for the client. Options 1, 2, and 3 are unrelated to this surgical complication.
The nurse is caring for a child diagnosed with Reye's syndrome. The nurse monitors for manifestations of which condition associated with this syndrome?
- A. Protein in the urine
- B. Symptoms of hyperglycemia
- C. Increased intracranial pressure
- D. A history of a staphylococcus infection
Correct Answer: C
Rationale: Reye's syndrome is an acute encephalopathy that follows a viral illness and is characterized pathologically by cerebral edema and fatty changes in the liver. Intracranial pressure and encephalopathy are major problems associated with Reye's syndrome. Protein is not present in the urine. Reye's syndrome is related to a history of viral infections, and hypoglycemia is a symptom of this disease.
The nurse reviews a primary health care provider's prescriptions and notes that a topical nitrate is prescribed. The nurse notes that acetaminophen is prescribed to be administered before the nitrate. The nurse implements the prescription with which understanding about why acetaminophen is prescribed?
- A. Headache is a common side effect of nitrates.
- B. Fever usually accompanies myocardial infarction.
- C. Acetaminophen potentiates the therapeutic effect of nitrates.
- D. Acetaminophen does not interfere with platelet action as acetylsalicylic acid (aspirin) does.
Correct Answer: A
Rationale: Headache occurs as a side effect of nitrates in many clients. Acetaminophen may be administered before nitrates to prevent headaches or minimize the discomfort from the headaches.
A child is admitted to the hospital with a diagnosis of rheumatic fever. The nurse reviews the blood laboratory findings, knowing that which finding will confirm the likelihood of this disorder?
- A. Increased leukocyte count
- B. Decreased hemoglobin count
- C. Increased antistreptolysin-O (ASO titer)
- D. Decreased erythrocyte sedimentation rate
Correct Answer: C
Rationale: Children suspected of having rheumatic fever are tested for streptococcal antibodies. The most reliable and best standardized test to confirm the diagnosis is the ASO titer. An elevated level indicates the presence of rheumatic fever. The remaining options are unrelated to diagnosing rheumatic fever. Additionally, an increased leukocyte count indicates the presence of infection but is not specific in confirming a particular diagnosis.
A client admitted to the hospital has been prescribed pyridostigmine. When assessing the client for side effects of the medication, the nurse should ask the client about the presence of which occurrence?
- A. Mouth ulcers
- B. Muscle cramps
- C. Feelings of depression
- D. Unexplained weight gain
Correct Answer: B
Rationale: Pyridostigmine is an acetylcholinesterase inhibitor used to treat myasthenia gravis, a neuromuscular disorder. Muscle cramps and small muscle contractions are side effects and occur as a result of overstimulation of neuromuscular receptors. Mouth ulcers, depression, and weight gain are not associated with this medication.