Nokea
When preparing a client for admission to the surgical suite, the nurse recognizes that which one of the following items is most important to remove before sending the client to surgery?
- A. Hearing aid
- B. Contact lenses
- C. Wedding ring
- D. Dentures
Correct Answer: B
Rationale: Contact lenses must be removed before surgery to prevent corneal damage or injury under anesthesia, especially if electrocautery is used, which could cause burns if foreign objects are present in the eyes.
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The doctor has ordered the removal of a Davol drain. Which of the following instructions should the nurse give to the client before removing the drain?
- A. The client should be told to breathe normally.
- B. The client should be told to take two or three deep breaths as the drain is being removed.
- C. The client should be told to hold his breath as the drain is being removed.
- D. The client should breathe slowly as the drain is being removed.
Correct Answer: C
Rationale: Holding the breath during Davol drain removal prevents air entry into the pleural space, reducing the risk of pneumothorax.
A client with chronic obstructive pulmonary disease (COPD) is admitted to the respiratory unit. Which physician prescription should the nurse question?
- A. Oâ‚‚ at 5 L/min by nasal cannula
- B. Solu Medrol 125 mg IV push every 6 hours
- C. Ceftriaxone (Rocephin) 1gram IVPB daily
- D. Darvocet N 100 po prn pain
Correct Answer: A
Rationale: High-flow oxygen (5 L/min) can suppress the hypoxic drive in COPD clients, risking CO2 retention. Low-flow oxygen (1-2 L/min) is safer and should be questioned.
A student in a cardiac unit is performing auscultation of a client's heart. The nurse recognizes that the student is performing pulmonic auscultation correctly when the stethoscope is placed:
- A. Between the apex and the sternum
- B. At the fifth intercostal space at the left midclavicular line
- C. At the second intercostal space, left of the sternum
- D. At the manubrium
Correct Answer: C
Rationale: The pulmonic area is auscultated at the second intercostal space, left of the sternum, where the pulmonary valve sounds are best heard.
A client's serum sodium level is 113 mEq/L. The nurse would expect which findings upon assessment?
- A. headache, confusion, muscle weakness, fatigue
- B. hypertension, muscle cramps, respiratory depression
- C. cardiac arrhythmia, tetany, tachycardia
- D. confusion, nystagmus, tetany, hallucinations
Correct Answer: A
Rationale: Severe hyponatremia (113 mEq/L) causes neurological symptoms like headache, confusion, muscle weakness, and fatigue due to cerebral edema.
The nurse caring for a client with a closed head injury obtains an intracranial pressure (ICP) reading of 17 mmHg. The nurse recognizes that:
- A. The ICP is elevated and the doctor should be notified.
- B. The ICP is normal; therefore, no further action is needed.
- C. The ICP is low and the client needs additional IV fluids.
- D. The ICP reading is not as reliable as the Glascow coma scale.
Correct Answer: A
Rationale: An ICP of 17 mmHg is elevated (normal is 7-15 mmHg), indicating increased intracranial pressure, which requires immediate notification of the physician.