Nokea
When assessing a client who has had spinal anesthesia, which of the following would the nurse expect to find?
- A. The client feels pain before moving the legs.
- B. The blood pressure is significantly increased.
- C. Sensation returns to the toes first, then progresses to the perineal area.
- D. The client complains of a headache while in the lying position.
Correct Answer: C
Rationale: After spinal anesthesia, sensation typically returns distally (toes) first, progressing proximally (perineal area), as the anesthetic wears off in a predictable pattern.
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A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?
- A. Use your nasal decongestant spray regularly to help clear your nasal passages.
- B. Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.
- C. It is important to increase your activity. A daily brisk walk will help promote drainage.
- D. Keep a diary of when your symptoms occur. This is a very small amount of the drug. You identify what precipitates your attacks.
Correct Answer: D
Rationale: Keeping a symptom diary helps identify triggers for allergic rhinitis, enabling avoidance or management strategies. Overuse of decongestant sprays can cause rebound congestion. Antibiotics are ineffective for allergic rhinitis, which is not bacterial. Increased activity like walking does not directly alleviate allergic rhinitis symptoms.
Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled?
- A. Muscle spasms.
- B. Nausea.
- C. Shivering.
- D. Dry mouth.
Correct Answer: B
Rationale: Ondansetron is an antiemetic, effective when nausea is controlled.
The nurse is preparing to administer an intradermal injection. Which of the following would be appropriate action by the nurse?
- A. Displace the skin to the side and inject at a 15 degree angle
- B. Position the needle bevel up at 15 degrees
- C. Position the needle bevel up at 45 degrees
- D. Position the needle bevel up at 90 degrees with a dart-like motion
Correct Answer: B
Rationale: Intradermal injections require a 15-degree angle with the bevel up to ensure shallow administration.
A physician orders vitamin B12 for a client with pernicious anemia. Which site is appropriate for the nurse to administer vitamin B12? Select all that apply.
- A. Deltoid.
- B. Greater femur trochanter.
- C. Acromion muscle.
- D. Ventrogluteal.
- E. Upper back.
- F. Dorsogluteal.
Correct Answer: A,D,F
Rationale: Vitamin B12 is administered intramuscularly, and appropriate sites include the deltoid, ventrogluteal, and dorsogluteal muscles, as these provide adequate muscle mass for absorption. The greater femur trochanter and acromion muscle are not standard injection sites, and the upper back is not suitable for intramuscular injections.
A client has been diagnosed with vasospastic disorder (Raynaud's phenomenon) on the tip of the nose and fingertips. The physician has prescribed reserpine (Serpasil) to determine if the client will obtain relief. The client's history reveals that he lives in Vermont and works outside in the logging industry. He smokes two packs of cigarettes a day. Which of the following components are an important part of the discharge plan for this client? Select all that apply.
- A. Stopping smoking
- B. Wearing a face covering and gloves in the winter
- C. Placing fingertips in cool water to rewarm them
- D. Finding employment that can be done in a warm environment
- E. Reporting signs of orthostatic hypotension
Correct Answer: A,B,D,E
Rationale: Rationales: A) Stopping smoking reduces vasoconstriction triggered by nicotine, critical in Raynaud's. B) Face covering and gloves protect against cold, a trigger for vasospasm. D) Working in a warm environment minimizes cold exposure. E) Reserpine may cause orthostatic hypotension, requiring monitoring. C) Cool water worsens vasospasm; warm water is recommended.