Nokea
The PACU nurse is caring for a patient who is presenting with agitation following knee replacement surgery. What action should the nurse take first?
- A. Notify the anesthesiologist of the adverse reaction.
- B. Assess the patient's respiratory function.
- C. Obtain an order for additional sedation to keep the patient safe during agitation.
- D. Administer a benzodiazepine antagonist.
Correct Answer: B
Rationale: Assessing respiratory function is the priority, as agitation post-surgery may signal hypoxia, a life-threatening issue. Notifying the anesthesiologist, sedation, and reversal agents are secondary after ruling out airway or breathing problems.
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While reviewing a client's medical record who has fallen twice in the past month, which medications should the nurse recommend be discontinued to lower the client's risk for future falls?
- A. Fluoxetine
- B. Temazepam
- C. Bupropion
- D. Ferrous sulfate
- E. Hydrocodone-acetaminophen
- F. Hydroxyzine
- G. Docusate
Correct Answer: B, E, F
Rationale: Temazepam (sedative), hydrocodone-acetaminophen (opioid), and hydroxyzine (sedating antihistamine) increase fall risk via drowsiness or dizziness. Fluoxetine, bupropion, ferrous sulfate, and docusate have lower fall risk.
The nurse provides discharge instructions to a client with a newly applied fiberglass cast for a fractured radius. Which of the following statements by the client would indicate a correct understanding of the teaching?
- A. The swelling can be reduced by keeping my extremity in a dependent position.'
- B. The edges of the cast can be cut with scissors until I feel comfortable.'
- C. To reduce pain and swelling, I should apply a warm compress.'
- D. If my cast gets slightly wet, pat it dry with a towel and try drying it with a hair dryer set on the cool setting.'
Correct Answer: D
Rationale: Drying a slightly wet fiberglass cast with a towel and a cool hair dryer is appropriate to prevent skin breakdown. A dependent position increases swelling, cutting the cast is unsafe, and warm compresses can worsen swelling and are not recommended.
The nurse is assessing a client who is newly diagnosed with rheumatoid arthritis (RA). Which of the following findings is consistent with this diagnosis?
- A. Janeway lesions
- B. Tophi
- C. Unilateral joint pain
- D. Low-grade fever
Correct Answer: D
Rationale: Low-grade fever is consistent with rheumatoid arthritis, a systemic inflammatory condition. Janeway lesions are linked to endocarditis, tophi to gout, and RA typically involves bilateral joint pain.
While training a new RN in the emergency department, the nurse attends to a client with Guillain-Barre Syndrome. The new RN asks what may have caused this condition. Which of the following occurrences in the patient's history is most likely a contributing factor?
- A. A spinal cord injury at age 12
- B. An upper respiratory infection about a month ago
- C. Hydrocephaly as an infant
- D. A joint injury as a teenager
Correct Answer: B
Rationale: Guillain-Barre Syndrome is often triggered by a recent infection, commonly an upper respiratory infection, leading to an autoimmune response against peripheral nerves. Spinal cord injury, hydrocephaly, and joint injury are unrelated.
The nurse is caring for a client experiencing an exacerbation of rheumatoid arthritis (RA). The nurse should obtain a prescription for
- A. Allopurinol.
- B. Verapamil.
- C. Prednisone.
- D. Methotrexate.
Correct Answer: C, D
Rationale: Prednisone (a corticosteroid) reduces acute inflammation, and methotrexate (a DMARD) manages chronic rheumatoid arthritis. Allopurinol treats gout, and verapamil is for cardiac issues.