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Which interventions should the nurse include in the plan of care for a client who is scheduled for a bronchoscopy? Select all that apply.
- A. Remove any dentures.
- B. Remove contact lenses.
- C. Provide access to limited food and drink.
- D. Ensure that the informed consent is signed.
- E. Have the client void before transport to endoscopy.
Correct Answer: A,B,D,E
Rationale: If the client has any contact lenses, dentures, or other prostheses, they are removed before sedation is administered to him or her. The client must sign an informed consent because the procedure is invasive. For comfort reasons, the client also should be asked about the need to void before transport to the endoscopy department. The client is not allowed to eat or drink usually for 6 to 8 hours (or as specified by the primary health care provider) before the procedure to prevent the risk of aspiration.
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The nurse is assessing a client with suspected appendicitis. Which of the following findings would support this diagnosis?
- A. Pain at McBurney's point.
- B. Decreased bowel sounds.
- C. Bradycardia.
- D. Fever of 99°F.
Correct Answer: A, B
Rationale: Pain at McBurney's point and decreased bowel sounds are classic signs of appendicitis due to peritoneal irritation and intestinal obstruction.
A client with a history of epilepsy is admitted with status epilepticus. The nurse should prioritize which of the following interventions?
- A. Administer lorazepam intravenously.
- B. Apply oxygen via nasal cannula.
- C. Insert a nasogastric tube.
- D. Position the client supine.
Correct Answer: A
Rationale: Lorazepam is the priority to stop seizures in status epilepticus.
You measure your 2 year old client's vital signs as: • Respiratory rate: 32 breaths per minute • Pulse: 110 beats per minute • Blood pressure: 55/82. The mother asks you if these vital signs are normal. You should respond to this mother's question by stating:
- A. The respiratory rate is a little too fast but the other vital signs are normal.'
- B. The pulse rate is a little too fast but the other vital signs are normal.'
- C. The blood pressure is a little low but the other vital signs are normal.'
- D. All of these vital signs are normal for a child that is 2 years of age.'
Correct Answer: C
Rationale: For a 2-year-old, normal ranges are approximately: respiratory rate 20-30 breaths/min, pulse 80-130 beats/min, blood pressure ~90/55 mmHg. The blood pressure (55/82) is low (systolic is below normal), while the respiratory rate and pulse are within or slightly above normal ranges.
A client is prescribed buspirone (BuSpar) 5mg two times a day. Which of the following statements indicates that the client has understood the nurse's teaching about this drug? Select all that apply.
- A. This medicine will make me sleepy
- B. BuSpar will relax my muscles
- C. My anxiety will be completely gone by tomorrow
- D. BuSpar will help me not to worry so much
- E. I'll be able to focus better
Correct Answer: D,E
Rationale: Buspirone reduces anxiety and improves focus without causing sedation or muscle relaxation. Expecting complete anxiety relief by tomorrow is unrealistic, as it takes weeks to be effective.
Which tool or scale would you use for a focused neurological assessment of your client?
- A. The Lazarus Cognitive Appraisal Scale
- B. The Hamilton Rating Scale
- C. The McGill Scale
- D. The Rancho Los Amigos Scale
Correct Answer: D
Rationale: The Rancho Los Amigos Scale is used for assessing levels of consciousness and cognitive recovery in patients with brain injuries, ideal for a focused neurological assessment.