The nurse is preparing to admit a client from the postanesthesia care

Planning

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Question 1 of 5.

The nurse is preparing to admit a client from the postanesthesia care unit who has had microvascular decompression of the trigeminal nerve. Which equipment should the nurse ask the unlicensed assistive personnel to make sure is at the bedside when the client arrives?

A. Flashlight and pulse oximeter

B. Cardiac monitor and suction equipment

C. Padded bed rails and suction equipment

D. Blood pressure cuff and cardiac monitor

Explanation: The postoperative care of the client having microvascular decompression of the trigeminal nerve is the same as for the client undergoing craniotomy. This client requires hourly neurological assessment as well as monitoring of the cardiovascular and respiratory statuses. Therefore, a flashlight and pulse oximetry are necessary items. Cardiac monitoring and padded bed rails are not indicated unless there is a special need based on a client history of cardiac disease or seizures, respectively. Suctioning is performed cautiously and only when necessary after craniotomy to avoid increasing the intracranial pressure.

Question 2 of 5.

The nurse is caring for a client who is receiving total parenteral nutrition through a central venous catheter. Which action should the nurse plan to implement to decrease the risk of infection in this client?

A. Track the client's oral temperature.

B. Administer antibiotics intravenously.

C. Evaluate the differential of the leukocytes.

D. Use sterile technique for dressing changes.

Explanation: Sterile technique is vital during dressing changes of a central venous catheter (CVC). CVCs are large-bore catheters that can serve as a direct-entry point for microorganisms into the heart and circulatory system. Using aseptic technique helps avoid catheter-related infections by preventing the introduction of potential pathogens to the site. Although the remaining options are reasonable nursing interventions for a client with a CVC, none of them prevents infection. Options 1 and 3 are assessment methods, and option 2 is implemented after the confirmation of an existing infection.

Question 3 of 5.

The nurse creates a plan of care for a client with a spica cast that covers a lower extremity. Which action should the nurse include in the plan of care to promote bowel elimination?

A. Use a bedside commode.

B. Ambulate to the bathroom.

C. Administer an enema daily.

D. Use a low-profile (fracture) bedpan.

Explanation: A client with a spica cast (body cast) that covers a lower extremity cannot bend at the hips to sit up. A low-profile bedpan or fracture pan is designed for use by clients with body or leg casts and for clients who have difficulty raising the hips to use a standard bedpan; therefore, using a commode or the bathroom is contraindicated. Daily enemas are not a part of routine care.

Question 4 of 5.

The nurse is caring for a postpartum client with thromboembolytic disease. Which intervention is most important to include when planning care to prevent the complication of pulmonary embolism?

A. Enforce bed rest.

B. Monitor the vital signs frequently.

C. Assess the breath sounds frequently.

D. Administer prescribed anticoagulant therapy.

Explanation: The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although the remaining options may be implemented for a client with thromboembolytic disease, the correct option will specifically assist in the prevention of pulmonary embolism.

Question 5 of 5.

The student nurse is listening to a lecture on serum electrolyte levels and the use of isotonic solutions. Which statement by the student nurse indicates that the teaching has been effective?

A. 10% dextrose in water is a hypotonic solution.

B. 3% sodium chloride solution is a hypotonic solution.

C. 5% dextrose in water is considered an isotonic solution.

D. 0.45% sodium chloride solution is a hypertonic solution.

Explanation: Five percent dextrose in water is an isotonic solution, which means that the osmolality of this solution matches normal body fluids. Other examples of isotonic fluids include 0.9% sodium chloride solution (normal saline) and lactated Ringer's solution. Ten percent dextrose in water and 3% sodium chloride solution are hypertonic solutions, and 0.45% sodium chloride solution is hypotonic.