Nokea
What is included in the routine assessment of the patient's cardiovascular function on admission to the PACU?
- A. Monitoring arterial blood gases
- B. Electrocardiographic (ECG) monitoring
- C. Determining fluid and electrolyte status
- D. Direct arterial blood pressure monitoring
Correct Answer: B
Rationale: ECG monitoring assesses cardiovascular function, detecting arrhythmias or ischemia.
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A client had an evacuation of a subdural hematoma. Which of the following actions should the nurse take first?
- A. Observe for cerebrospinal fluid (CSF) leaks from the evacuation site.
- B. Assess for an increase in temperature.
- C. Check the oximeter.
- D. Monitor for manifestations of increased intracranial pressure.
Correct Answer: C
Rationale: Step 1: Checking the oximeter is essential to assess the client's oxygen saturation levels immediately post-procedure.
Step 2: Hypoxia can lead to serious complications, impacting the client's neurological status.
Step 3: The nurse must prioritize oxygenation status to prevent further brain injury or hypoxemia.
Step 4: Observing for CSF leaks, assessing temperature, and monitoring ICP are important but not as immediate as ensuring adequate oxygen supply.
Summary: Option C is correct as it addresses the most critical and immediate concern post-procedure, ensuring optimal oxygenation for the client's neurological recovery. Options A, B, and D are important but secondary to maintaining oxygen levels.
What is the primary goal of treating diabetic retinopathy?
- A. Prevent vision loss
- B. Restore lost vision
- C. Improve color vision
- D. None of the above
Correct Answer: A
Rationale: Early treatment aims to prevent further vision loss in diabetic retinopathy.
When a client develops an airway obstruction from a foreign body but remains conscious, which of the following actions should the nurse take first?
- A. Insert an oral airway
- B. Administer the abdominal thrust maneuver
- C. Turn the client to the side
- D. Perform a blind finger sweep
Correct Answer: B
Rationale: The correct action is to administer the abdominal thrust maneuver (Heimlich maneuver) first to attempt to dislodge the foreign body. This is the priority intervention when a conscious client is experiencing airway obstruction. Inserting an oral airway (Choice A) may worsen the obstruction. Turning the client to the side (Choice C) does not directly address the airway obstruction. Performing a blind finger sweep (Choice D) is not recommended as it can push the object further down the airway. Administering the abdominal thrust maneuver is the most effective and safest initial intervention to clear the airway obstruction.
Anne asks how a chest x-ray would help the physician examine her heart. You respond by saying
- A. A chest x-ray is used to rule out that a fractured rib caused your pain.
- B. The chest x-ray is an error. I will cancel the order.
- C. A chest x-ray is used to detect the size and position of the heart.
- D. All patients who are admitted must have a chest x-ray.
Correct Answer: C
Rationale: Chest x-rays provide information about heart size and position.
When reviewing the provider's orders, a nurse recognizes that clarification is needed for which of the following medications in a client experiencing an exacerbation of asthma?
- A. Propranolol
- B. Theophylline
- C. Montelukast
- D. Prednisone
Correct Answer: A
Rationale: The correct answer is A: Propranolol. Propranolol is a beta-blocker that can exacerbate asthma symptoms by causing bronchoconstriction. This medication is contraindicated in patients with asthma. The other choices (B: Theophylline, C: Montelukast, D: Prednisone) are commonly used in the management of asthma exacerbations and do not typically require clarification in this context. Theophylline is a bronchodilator, Montelukast is a leukotriene receptor antagonist, and Prednisone is a corticosteroid used for its anti-inflammatory effects in asthma.