Nokea
The nurse is preparing a client for a herniorrhaphy. It would be MOST important for the nurse to complete which of the following one hour prior to surgery?
- A. Administer an enema.
- B. Confirm that the consent form has been signed.
- C. Perform a preoperative shave and scrub.
- D. Evaluate for food or medication allergies.
Correct Answer: B
Rationale: surgical consent should be rechecked prior to going to surgery
You may also like to solve these questions
A client with internal radiation.
Which of the following actions, if taken by the nurse, is MOST important?
- A. Restrict visitors who may have an upper respiratory infection.
- B. Assign only male caregivers to the client.
- C. Plan nursing activities to decrease nurse exposure.
- D. Wear a lead-lined apron whenever delivering client care.
Correct Answer: C
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) all visitors are restricted with regard to the distance they should be from the client (2) not relevant to the situation (3) correct-principles for radiation therapy are time, distance, shielding; nurse should decrease the time spent in close proximity to the client (4) appropriate shielding (lead aprons) is to be used when the nurse has to spend any length of time at a close distance, not just for routine care
An elderly man diagnosed with chronic schizophrenia is being followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and has recently developed symptoms of tardive dyskinesia.
The nurse's documentation on this client should include
- A. assessment of ADL (self-care) ability.
- B. Mini-Mental Status Examination (MMSE).
- C. Abnormal Involuntary Movement Scale (AIMS).
- D. Modified Overt Aggression Scale (MOAS).
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) assessment of client's abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill (2) measures cognitive function (3) correct-is most widely accepted examination to Test for the presence of tardive dyskinesia (4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population
The nurse in the outpatient clinic teaches a young adult with a sprained right ankle to walk with a cane. While teaching the client to use the cane, how should the nurse be positioned?
- A. Standing on the client's left side and slightly behind the client.
- B. Standing on the client's right with one hand on the client's waist.
- C. Standing directly in front of the woman with both hands on the client's arms.
- D. Standing in front of the client on the right side.
Correct Answer: A
Rationale: stand slightly behind patient on strong side
The nurse is caring for a client with a history of anxiety who is receiving lorazepam (Ativan) 0.5 mg PO tid. Which of the following findings should the nurse report immediately?
- A. Mild sedation.
- B. Dry mouth.
- C. Dizziness upon standing.
- D. Insomnia.
Correct Answer: C
Rationale: Dizziness upon standing suggests orthostatic hypotension, a serious lorazepam side effect. Options A, B, and D are common.
The nurse is caring for a client who is receiving a continuous IV infusion of fentanyl for pain management. Which of the following findings should the nurse report immediately?
- A. Respiratory rate of 10 breaths/min
- B. Blood pressure of 120/80 mmHg
- C. Heart rate of 80 bpm
- D. Oxygen saturation of 95%
Correct Answer: A
Rationale: A respiratory rate of 10 breaths/min indicates respiratory depression, a serious fentanyl side effect. Options B, C, and D are normal findings.