Nokea
Which teaching point is essential for a client with a seizure disorder?
- A. Avoid all physical activity.
- B. Take medications as prescribed.
- C. Limit sleep to 6 hours nightly.
- D. Restrict fluid intake.
Correct Answer: B
Rationale: Taking medications as prescribed is essential to control seizures and prevent recurrence.
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The sarge department (ED) nurse cares for a client with suspected shock and is prescribed a large volume of sodium chloride (normal saline) The nurse plans on starting which gauge peripheral vascular
- A. 18-gauge
- B. 22-gauge
- C. 24-gauge
- D. 26-gauge
Correct Answer: A
Rationale: An 18-gauge catheter is appropriate for rapid infusion of large fluid volumes in shock.
The nurse anticipates that a client who has received propofol (Diprivan) as the induction and maintenance agent for general anesthesia will most likely experience:
- A. Minimal nausea and vomiting.
- B. Hypotension.
- C. Slow induction of anesthesia.
- D. Small tremors of the skeletal muscles.
Correct Answer: A
Rationale: Propofol is associated with minimal postoperative nausea and vomiting, making it a preferred agent for many surgeries, especially outpatient procedures.
What is the priority nursing action for a client with a suspected neurological deficit?
- A. Perform a full neurological assessment.
- B. Administer pain medication.
- C. Monitor vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Monitoring vital signs is the priority to ensure stability and detect acute changes in a client with a suspected neurological deficit.
A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which of the following interventions should the nurse include in the plan of care?
- A. Maintain the head of the bed at 30 to 40 degrees.
- B. Teach the client how to use esophageal speech.
- C. Initiate small feedings of soft goods.
- D. Irrigate drainage tubes as needed.
Correct Answer: A
Rationale: Elevating the head of the bed 30–40 degrees reduces swelling and maintains airway patency post-laryngectomy. Esophageal speech training is premature immediately post-surgery. Feedings are typically delayed until swallowing is safe. Drainage tubes are not routinely irrigated.
A client is scheduled for an elective splenectomy. Immediately before the client goes to surgery, the nurse should determine that the client has:
- A. Voided completely.
- B. Signed the consent.
- C. Vital signs recorded.
- D. Name band on wrist.
Correct Answer: B
Rationale: Verifying that the client has signed the consent form is the priority before surgery to ensure informed consent and legal compliance. Voiding, recording vital signs, and checking the name band are also important but secondary to consent verification.