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: The correct answer is D: “Remain supine for the time specified by the physician.” After a subarachnoid block, the client must remain lying down to prevent complications like spinal headaches due to cerebrospinal fluid leakage. This position helps maintain adequate spinal fluid pressure. Choice A is incorrect as fluid intake is important postoperatively. Choice B is not relevant to a subarachnoid block. Choice C is important but not the most crucial instruction compared to maintaining the supine position.
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After reviewing the database, the nurse discovers that the patient’s vital signs have not been recorded by the nursing assistive personnel (NAP). Which clinical decision should the nurse make? Administer scheduled medications assuming that the NAP would have reported
- A. abnormal vital signs. Have the patient transported to the radiology department for a scheduled x-ray, and
- B. review vital signs upon return.
- C. Ask the NAP to record the patient’s vital signs before administering medications.
- D. Omit the vital signs because the patient is presently in no distress.
Correct Answer: C
Rationale: Step 1: Safety First - The nurse's priority is patient safety. Without vital signs, medication administration can be unsafe.
Step 2: Accountability - The nurse must ensure accurate and timely vital signs recording before making clinical decisions.
Step 3: Delegation - Asking the NAP to record vital signs aligns with their role and helps maintain a reliable record.
Step 4: Proactive Approach - By having the NAP record vital signs, the nurse can make informed decisions based on accurate data.
Summary:
A: Incorrect - Proceeding with medications without vital signs can risk patient safety.
B: Incorrect - Waiting to review vital signs later can delay necessary interventions.
D: Incorrect - Omitting vital signs is negligent and compromises patient care.
A patient is unable to control his bowels ff. a subarachnoid hemorrhage. Which intervention by the nurse can help reduce episodes of bowel incontinence?
- A. Ask the patient frequently if he has to have a bowel movement
- B. Place incontinence pads on the patient’s bed and chair
- C. Toilet the patient according to his pre-illness schedule, whether or not he feels the urge
- D. Take care not to embarrass the patient when incontinent episode occur
Correct Answer: C
Rationale: The correct answer is C: Toilet the patient according to his pre-illness schedule, whether or not he feels the urge. This intervention helps establish a routine for bowel movements, which can aid in reducing episodes of bowel incontinence. By following the patient's pre-illness schedule, the nurse can help regulate bowel movements and prevent accidents.
A: Asking the patient frequently if he has to have a bowel movement may not address the underlying issue of bowel incontinence.
B: Placing incontinence pads on the patient's bed and chair is a reactive measure and does not address the root cause of the issue.
D: Taking care not to embarrass the patient when incontinent episodes occur is important for emotional support but does not directly address reducing episodes of bowel incontinence.
A nurse is preparing to carry out interventions. Which resources will the nurse make sure are available? (Select all that apply.)
- A. Equipment
- B. Safe environment
- C. Confidence
- D. Assistive personnel
Correct Answer: A
Rationale: The correct answer is A: Equipment. The nurse needs to ensure that necessary equipment is available to carry out interventions effectively and safely. Without the right equipment, the nurse may not be able to provide appropriate care. Safe environment (B) is important but not a resource that the nurse makes sure is available. Confidence (C) is a personal attribute and not a resource. Assistive personnel (D) are individuals who can help but are not resources that the nurse ensures are available.
A febrile patient’s fluid output is in excess of normal because of diaphoresis. The nurse should plan fluid replacement based on the knowledge that insensible losses in an afebrile person are normally not greater than:
- A. 300ml/24hr
- B. 900ml/24hr
- C. 600ml/24hr
- D. 1200ml/24hr
Correct Answer: C
Rationale: The correct answer is C (600ml/24hr) because insensible fluid losses in an afebrile person are typically around 600ml per 24 hours. Insensible losses include water lost through the skin as sweat and through the lungs during respiration. These losses are not easily quantifiable but are estimated to be around 600ml/day in normal circumstances. Choices A, B, and D are incorrect because they are either too low (A and B) or too high (D) compared to the normal range of insensible fluid losses. Selecting C as the correct answer is based on the understanding of physiological principles related to fluid balance and normal body functions.
Which of the following types of cells is the immune system’s shutoff mechanism?
- A. Plasma cells
- B. Suppressor T cells
- C. Helper T cells
- D. B lymphocytes
Correct Answer: B
Rationale: The correct answer is B: Suppressor T cells. Suppressor T cells regulate the immune response by inhibiting the activity of other immune cells to prevent overreaction and maintain immune balance. They play a crucial role in preventing autoimmune diseases and excessive inflammation. Plasma cells (A) produce antibodies, Helper T cells (C) assist in activating other immune cells, and B lymphocytes (D) are involved in antibody production. Suppressor T cells specifically have the function of shutting down immune responses, making them the immune system’s shutoff mechanism.