Nokea
When assessing a client for early septic shock, the nurse observes for which of the following?
- A. Cool, clammy skin.
- B. Warm, flushed skin.
- C. Decreased systolic blood pressure.
- D. Hemorrhage.
Correct Answer: B
Rationale: Early septic shock is characterized by vasodilation and increased cardiac output, leading to warm, flushed skin. Cool, clammy skin and decreased blood pressure occur in later stages, and hemorrhage is not a feature of septic shock.
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The nurse learns that a client who is scheduled for a tonsillectomy has been taking 40 mg of oral prednisone daily for the last week for poison ivy on his leg. What is the nurse's best action?
- A. Document the prednisone with current medications.
- B. Notify the surgeon of the poison ivy.
- C. Notify the anesthesiologist of the prednisone administration.
- D. Send the client to surgery.
Correct Answer: C
Rationale: Prednisone use affects adrenal function and stress response, increasing risks during anesthesia. Notifying the anesthesiologist ensures proper perioperative management, such as stress-dose steroids.
A client with Parkinson's disease asks the nurse to explain to his nephew "what the doctor said the pallidotomy would do." The nurse's best response includes stating that the main goal for the client after pallidotomy is improved:
- A. Functional ability.
- B. Emotional stress.
- C. Alertness.
- D. Appetite.
Correct Answer: A
Rationale: Pallidotomy aims to improve functional ability by reducing symptoms like tremors and rigidity. Emotional stress, alertness, and appetite are not primary targets of this procedure.
A client with cirrhosis begins to develop ascites. Spironolactone (Aldactone) is prescribed to treat the ascites. The nurse should monitor the client closely for which of the following drug-related adverse effects?
- A. Constipation.
- B. Hyperkalemia.
- C. Irregular pulse.
- D. Dysuria.
Correct Answer: B
Rationale: Spironolactone, a potassium-sparing diuretic, can cause hyperkalemia (B), a critical adverse effect. Constipation (A), irregular pulse (C), and dysuria (D) are not commonly associated.
A client is in balanced suspension traction using a half-ring Thomas splint with a Pearson attachment that suspends the lower extremity and applies direct skeletal traction for a hip fracture. Which of the following nursing assessments would not be appropriate?
- A. Greater trochanter skin checks.
- B. Pin site inspection.
- C. Neurovascular checks proximal to the splint.
- D. Foot movement evaluation.
Correct Answer: C
Rationale: Neurovascular checks proximal to the splint are less relevant, as distal checks assess circulation and nerve function affected by the fracture and traction.
After an intravenous pyelogram (IVP), the nurse should not include incorporating which of the following measures into the client's plan of care?
- A. Maintaining bed rest.
- B. Encouraging adequate fluid intake.
- C. Assessing for hematuria.
- D. Administering a laxative.
Correct Answer: D
Rationale: Administering a laxative is unnecessary post-IVP, as it does not aid recovery or contrast excretion, unlike fluid intake or hematuria assessment.