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The OR nursing staff are preparing a client for a surgical procedure. The anesthesiologist has given the client medications, and the client has entered the induction stage of anesthesia. The nursing staff can expect which of the following symptoms and activities from the client during this time?
- A. Irregular breathing patterns
- B. Minimal heartbeat, dilated pupils
- C. Relaxed muscles, regular breathing, constricted pupils
- D. Euphoria, drowsiness, dizziness
Correct Answer: D
Rationale: During the induction stage of anesthesia, the client may exhibit symptoms like euphoria, drowsiness, or dizziness. This stage occurs after the administration of medications by the anesthesiologist and ends when the client loses consciousness. Choice A is incorrect as irregular breathing patterns are not typically associated with the induction stage. Choice B is incorrect as minimal heartbeat and dilated pupils are not commonly observed during this stage. Choice C is incorrect as relaxed muscles, regular breathing, and constricted pupils are not indicative of the induction stage of anesthesia.
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The nurse is providing home care instructions to a client recovering from an acute inferior myocardial infarction (MI) with recurrent angina. What instruction should the nurse provide to this client?
- A. Avoid sexual intercourse for at least 4 months.
- B. Replace sublingual nitroglycerin tablets yearly.
- C. Participate in an exercise program that includes overhead lifting and reaching.
- D. Recognize the adverse effects of acetylsalicylic acid (aspirin), which include tinnitus and hearing loss.
Correct Answer: D
Rationale: After an acute MI, many clients are instructed to take an aspirin daily. Adverse effects include tinnitus, hearing loss, epigastric distress, gastrointestinal bleeding, and nausea. Sexual intercourse usually can be resumed in 4 to 8 weeks after an acute MI if the primary health care provider agrees and if the client has been able to achieve traditional parameters such as climbing two flights of steps without chest pain or dyspnea. Clients should be advised to purchase a new supply of nitroglycerin tablets every 6 months. Expiration dates on the medication bottle should also be checked. Activities that include lifting and reaching over the head should be avoided because they reduce cardiac output.
A nurse is caring for an 83-year-old man who has had swallowing difficulties. All of the following interventions are appropriate for this client EXCEPT:
- A. Keep the client in an upright position at all times
- B. Auscultate lung sounds every shift and after feedings
- C. Maintain suction equipment at the client's bedside
- D. Instruct the client about how to perform swallowing exercises
Correct Answer: A
Rationale: When caring for a client with swallowing difficulties, it is crucial to prevent aspiration of food into the lungs. Appropriate interventions include auscultating lung sounds every shift and after feedings to assess for any changes in breathing patterns, maintaining suction equipment at the client's bedside in case of difficulties, and providing instruction on swallowing exercises. Keeping the client in an upright position at all times is not necessary and may not always be feasible or comfortable for the client. This rigid requirement is not part of the standard care protocol for managing swallowing difficulties.
A client diagnosed with anxiety disorder is prescribed buspirone orally. When the client reports that it is difficult to swallow the tablets, the nurse provides which instruction to promote compliance?
- A. Crush the tablets before taking them.
- B. Mix the tablet uncrushed in applesauce.
- C. Purchase the liquid preparation with the next refill.
- D. Call the primary health care provider for a change in medication.
Correct Answer: A
Rationale: Buspirone tablets may be crushed and administered without regard to meals, making this the most effective instruction to promote compliance for a client who finds swallowing difficult. Mixing the tablet uncrushed in applesauce does not address the swallowing issue. Buspirone is not available in liquid form, and calling the primary health care provider for a medication change is premature before trying this intervention.
A healthcare professional is preparing to insert an indwelling catheter in a female client. Which of the following positions of the client is most appropriate for this procedure?
- A. Lithotomy position
- B. Prone position
- C. Dorsal recumbent position
- D. High Fowler's position
Correct Answer: C
Rationale: When preparing to insert an indwelling catheter for a female client, the most appropriate position is the dorsal recumbent position. In this position, the client lies on their back with knees bent. This position allows for easy access to the urethral area for catheter insertion. The lithotomy position, with legs elevated and spread apart, is more invasive and typically used for gynecological exams. The prone position, lying face down, is not suitable for catheter insertion. High Fowler's position, sitting upright at a 90-degree angle, is not ideal for catheter insertion as it does not provide proper access to the perineal area.
A client is receiving education on cholesterol. Which of the following statements from the client indicates the need for further teaching?
- A. I would like my HDL levels to be over 50.
- B. It is better for me to have high HDL levels and low LDL levels.
- C. It is better for me to have high LDL levels and low HDL levels.
- D. My goal is to get my total cholesterol below 200.
Correct Answer: C
Rationale: The correct answer is, 'It is better for me to have high LDL levels and low HDL levels.' This statement indicates a need for further teaching because high LDL levels contribute to atherosclerosis, while high HDL levels can protect against heart disease. The client should understand the importance of lowering LDL levels and increasing HDL levels to maintain good heart health. Choice A is correct as desiring HDL levels over 50 is a positive goal. Choice B is correct as it reflects the ideal scenario of high HDL and low LDL levels. Choice D is correct as a total cholesterol below 200 is a common goal for heart health. Therefore, Choice C is incorrect as it suggests an opposite and unhealthy relationship between LDL and HDL levels.