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What is the primary goal of the circulating nurse during preparation of the operating room, transferring and positioning the patient, and assisting the anesthesia team?
- A. Avoiding any type of injury to the patient
- B. Maintaining a clean environment for the patient
- C. Providing for patient comfort and sense of well-being
- D. Preventing breaks in aseptic technique by the sterile members of the team
Correct Answer: D
Rationale: The circulating nurse ensures aseptic practices are maintained throughout the surgical procedure.
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A nurse is assessing a client with a history of seizures. Which assessment finding requires immediate intervention?
- A. The client is experiencing an aura.
- B. The client's antiseizure medication level is within the therapeutic range.
- C. The client has been seizure-free for 2 years.
- D. The client's seizure activity lasts longer than 5 minutes.
Correct Answer: D
Rationale: The correct answer is D because prolonged seizures lasting longer than 5 minutes can lead to status epilepticus, a medical emergency that can cause brain damage or even death. Immediate intervention is necessary to stop the seizure activity. Auras (A) are warning signs of an impending seizure and do not require immediate intervention. Antiseizure medication within therapeutic range (B) indicates proper management. Being seizure-free for 2 years (C) is a positive outcome but does not require immediate intervention unless a seizure occurs.
A client with cirrhosis is experiencing ascites. Which dietary instruction should the nurse provide?
- A. Increase protein intake.
- B. Limit fluid intake to 1500 mL/day.
- C. Consume a low-sodium diet.
- D. Take a daily multivitamin.
Correct Answer: C
Rationale: The correct answer is C: Consume a low-sodium diet. Ascites in cirrhosis is often due to fluid retention caused by impaired liver function. A low-sodium diet helps to reduce fluid buildup in the body, alleviating ascites. Increasing protein intake (A) may worsen ascites by increasing fluid retention. Limiting fluid intake (B) can lead to dehydration, exacerbating the condition. Taking a daily multivitamin (D) may be beneficial for overall health but does not directly address ascites.
Joan asks you why she is being administered so many arterial blood gas tests. You respond by saying
- A. This test determines if your liver and kidneys are functioning properly.
- B. This test determines if you have sufficient WBC to fight infection.
- C. This test determines if you are hyperglycemic, which is a side effect of your medication.
- D. This test determines how well your tissues are oxygenated.
Correct Answer: D
Rationale: Arterial blood gas tests measure oxygenation and acid-base balance in the blood.
You anticipate that the physician will order which drug for status epilepticus?
- A. PO phenytoin and carbamazepine
- B. IV lorazepam (Ativan)
- C. IV carbamazepine
- D. IV magnesium sulfate
Correct Answer: B
Rationale: Lorazepam is commonly used for rapid control of seizures in status epilepticus.
What drug would be most effective in relieving Mr. Stout’s bronchial spasm?
- A. Potassium iodide
- B. Ephedrine sulfate
- C. Cromolyn sodium
- D. Acetylcysteine (Mucomyst)
Correct Answer: B
Rationale: Ephedrine stimulates beta-adrenergic receptors, relaxing bronchial smooth muscle.