Nokea
When preparing a teaching plan for an adult client about general anesthesia induction, which explanation would be most appropriate?
- A. œYour premedication will put you to sleep.'
- B. œYou will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy.'
- C. œYou will receive intravenous medication to make you sleepy.'
- D. œYou will breathe in medication through a facial mask to make you sleepy.'
Correct Answer: C
Rationale: For adults, explaining that intravenous medication induces sleep is accurate and simple, avoiding overwhelming details while addressing the primary method of general anesthesia induction.
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A client with neutropenia is at risk for sepsis. Which of the following is the earliest sign the nurse should monitor for?
- A. Hypotension.
- B. Tachycardia.
- C. Oliguria.
- D. Confusion.
Correct Answer: B
Rationale: Tachycardia is often the earliest sign of sepsis, reflecting the body's response to infection, and requires prompt monitoring in a neutropenic client.
The nurse is evaluating the discharge teaching for a client who has an ileal conduit. Which of the following statements indicates that the client has correctly understood the teaching? Select all that apply.
- A. If I limit my fluid intake, I will not have to empty my ostomy pouch as often.
- B. I can place an aspirin tablet in my pouch to decrease odor.
- C. I can usually keep my ostomy pouch on for 3 to 7 days before changing it.
- D. I must use a skin barrier to protect my skin from urine.
- E. I should supply my ostomy pouch of urine when it is full.
Correct Answer: C,D
Rationale: Keeping the pouch on for 3-7 days and using a skin barrier are correct practices. Limiting fluids increases infection risk, aspirin is unsafe, and the last option is unclear but likely a typo for emptying when full, which is correct but not listed as such.
A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order should the nurse assess these clients?
- A. A client with an endotracheal tube transferred out of the intensive care unit that day.
- B. A client with type 2 diabetes who had a cerebrovascular accident 4 days ago.
- C. A client with cellulitis of the left lower extremity with a fever of 100.8°F (38.2°C).
- D. A client receiving D5W I.V. at 125 mL/hour with 75 mL remaining.
Correct Answer: A,C,B,D
Rationale: The client with a new endotracheal tube (A) is highest priority due to airway risk. The febrile client with cellulitis (C) is next for infection monitoring. The stroke client (B) is stable 4 days post-event. The I.V. fluid client (D) is lowest priority.
The nurse is preparing to administer a medication to a client with a history of Clostridium difficile infection. Which precaution is most important?
- A. Wear a face mask during administration.
- B. Use a dedicated stethoscope for the client.
- C. Administer the medication in a private room.
- D. Clean the medication cart with alcohol wipes.
Correct Answer: B
Rationale: Using a dedicated stethoscope for a client with C. difficile prevents cross-contamination, as the infection spreads via contact with contaminated surfaces. A face mask is unnecessary, a private room is ideal but not always required, and alcohol wipes are ineffective against C. difficile spores. CN: Safety and infection control; CL: Synthesize
A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason for using this drug is that it helps:
- A. Slow progression of exophthalmos.
- B. Reduce the vascularity of the thyroid gland.
- C. Decrease the body's ability to store thyroxine.
- D. Increase the body's ability to excrete thyroxine.
Correct Answer: B
Rationale: SSKI reduces the vascularity of the thyroid gland, making surgery safer by decreasing the risk of bleeding. It does not primarily affect exophthalmos, thyroxine storage, or excretion.