Nokea
The nurse is preparing to provide preoperative teaching with a client scheduled for radical neck dissection. Which topic should the nurse initially focus on?
- A. The client's usual coping behaviors
- B. The client's dependable support systems
- C. Postoperative communication techniques
- D. The information already supplied by the surgeon
Correct Answer: D
Rationale: The first step in client education is establishing what the client already knows. This allows the nurse to correct any misinformation or misunderstandings, determine the starting point for teaching, and plan and implement the education at the client's level. Although the remaining options can be a component of the plan, the first step in client education is establishing what the client already knows.
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Which of the following is appropriate for a client with metabolic alkalosis?
- A. Monitor serum potassium levels
- B. Maintain the client on bed rest
- C. Have the client inhale carbon dioxide using a paper bag
- D. Administer sodium bicarbonate as ordered
Correct Answer: A
Rationale: Metabolic alkalosis can cause hypokalemia, so monitoring serum potassium levels is appropriate. Bed rest is not indicated, inhaling CO2 is for respiratory alkalosis, and sodium bicarbonate would worsen alkalosis.
A client with a history of bipolar disorder is prescribed lamotrigine (Lamictal). The nurse should instruct the client to report which of the following side effects immediately?
- A. Mild headache.
- B. Rash.
- C. Nausea.
- D. Fatigue.
Correct Answer: B
Rationale: A rash may indicate a serious hypersensitivity reaction to lamotrigine, such as Stevens-Johnson syndrome, requiring immediate reporting.
A client experiencing a mild panic attack has the following arterial blood gas (ABG) results: pH 7.49, PCO2 31 mm Hg, PaO2 97 mm Hg, HCO3 22 mEq/L. The nurse reviews the results and determines that the client has which acid-base disturbance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Respiratory acidosis
- D. Respiratory alkalosis
Correct Answer: D
Rationale: Acidosis is defined as a pH of less than 7.35, whereas alkalosis is defined as a pH of greater than 7.45. Respiratory alkalosis is present when the PCO2 is less than 35, whereas respiratory acidosis is present when the PCO2 is greater than 45. Metabolic acidosis is present when the HCO3 is less than 22 mEq/L, whereas metabolic alkalosis is present when the HCO3 is greater than 26 mEq/L. This client's ABGs are consistent with respiratory alkalosis.
Prochlorperazine (Compazine) is prescribed postoperatively. The nurse should evaluate the drug's therapeutic effect when the client expresses relief from which of the following?
- A. Nausea.
- B. Dizziness.
- C. Abdominal spasms.
- D. Abdominal distention.
Correct Answer: A
Rationale: Prochlorperazine is primarily used to treat postoperative nausea and vomiting, so relief from nausea indicates therapeutic effectiveness.
A postpartum client is experiencing heavy lochia 3 days after delivery. Which action should the nurse take first?
- A. Massage the fundus
- B. Administer oxytocin as ordered
- C. Encourage the client to ambulate
- D. Notify the physician
Correct Answer: A
Rationale: Heavy lochia may indicate uterine atony. Massaging the fundus is the first step to promote uterine contraction and reduce bleeding before escalating to other interventions.