Nokea
What is the most important postoperative instruction the nurse must give a client who has just returned from the operating room after receiving a subarachnoid block?
- A. "Avoid drinking liquids until the gag reflex returns."
- B. "Avoid eating milk products for 24 hours."
- C. "Notify a nurse if you experience blood in your urine."
- D. "Remain supine for the time specified by the physician."
Correct Answer: D
Rationale: After receiving a subarachnoid block, the client may experience a sudden drop in blood pressure that can lead to complications such as dizziness or fainting upon standing. Therefore, it is crucial for the client to remain in a supine position for the duration specified by the physician to allow for proper monitoring and management of any potential postoperative complications. This instruction helps prevent the occurrence of hypotension and other adverse effects by allowing adequate time for the block to wear off and for the body to adjust to changes in blood pressure. It also ensures the safety and well-being of the client during the immediate postoperative period.
You may also like to solve these questions
Which white blood cells are involved in releasing histamine during an allergic reaction?
- A. Basophils
- B. Monocytes
- C. Eosinophils
- D. Neutrophils
Correct Answer: A
Rationale: Basophils are a type of white blood cell that are involved in releasing histamine during an allergic reaction. When an allergen triggers the immune system, basophils release histamine and other chemical mediators. Histamine plays a key role in the inflammatory response associated with allergies, leading to symptoms such as itching, hives, and swelling. Basophils are known for their role in allergic reactions and are an important part of the body's defense against parasites and in the inflammatory response.
Clay is an 8-year-old boy diagnosed with heart failure. Which of the following shows that he is strictly following the directed therapeutic regimen?
- A. Daily use of an antibiotic
- B. Pulse rate less than 50 beats/minute
- C. Normal weight for age
- D. Elevation in red blood cell (RBC) count
Correct Answer: C
Rationale: In a young child like Clay who is diagnosed with heart failure, following the directed therapeutic regimen would involve maintaining a normal weight for his age. Weight monitoring is crucial in managing heart failure as excessive weight gain could lead to worsening of symptoms and complications. Ensuring that Clay stays within a normal weight range for his age shows his adherence to dietary recommendations, fluid restrictions, and overall treatment plan aimed at managing his heart failure effectively. Monitoring his weight would also help healthcare providers assess if the treatment plan is working and make necessary adjustments as needed. Therefore, Clay maintaining a normal weight for his age indicates that he is strictly following the directed therapeutic regimen for his heart failure.
Which is most important in the immediate care of the newborn?
- A. Maintain patent airway.
- B. Maintain stable body temperature.
- C. Administer prophylactic eye care.
- D. Establish identification of mother and baby.
Correct Answer: A
Rationale: Maintaining a patent airway is the most critical aspect in the immediate care of a newborn. An open airway is essential for the newborn to breathe effectively and receive adequate oxygen. Any obstruction in the airway can lead to respiratory distress and compromise the baby's oxygenation. Therefore, ensuring the airway is clear and the newborn can breathe properly is the top priority in providing immediate care. While other choices are important aspects of newborn care, ensuring a patent airway takes precedence in order to support the newborn's respiratory function and overall well-being.
A woman delivers a 3,250 g neonate at 42 weeks' gestation. Which physical finding is expected during an examination if this neonate?
- A. Abundant lanugo
- B. Absence of sole creases
- C. Breast bud of 1-2 mm in diameter
- D. Leathery, cracked, and wrinkled skin
Correct Answer: D
Rationale: A neonate born at 42 weeks' gestation, also known as post-term, is expected to have skin that appears leathery, cracked, and wrinkled due to prolonged exposure to the amniotic fluid in utero. This is a common physical finding in post-term neonates due to the decreased amount of vernix caseosa and amniotic fluid present on the skin at birth. Abundant lanugo (fine hair), absence of sole creases, and breast bud development are more commonly seen in preterm or term newborns, rather than post-term newborns.
What is an important consideration for the nurse who is communicating with a very young child?
- A. Speak loudly, clearly, and directly.
- B. Use transition objects, such as a doll.
- C. Disguise own feelings, attitudes, and anxiety.
- D. Initiate contact with child when parent is not present.
Correct Answer: B
Rationale: When communicating with a very young child, using transition objects, such as a doll, can help create a sense of familiarity, comfort, and security. These objects can serve as a bridge for the child to express themselves and can also provide a point of reference for the nurse to better understand the child's perspective. Additionally, transition objects can help the child feel more at ease during interactions with healthcare providers, making the communication process smoother and more effective.