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Sudden chest pain combined with dyspnea, cyanosis, and tachycardia are
symptoms associated with which of the following complications of surgery?
a. Hypovolemic shock
b. Dehiscence
c. Atelectasis
d. Pulmonary embolus - ANSWER-d. Pulmonary embolus
A client presents to the emergency department with signs of a stroke. After a
computed tomography (CT) scan, which revealed a hemorrhage, the nurse
anticipates directives for which
,one of the following plans?
A. TPA administration
B. Call a code blue
C. Prep for a client surgery
D. Place the client in Trendelenburg - ANSWER-b. Prep for a client surgery
A client arrives in the emergency department with an ischemic stroke. Because the
healthcare team is considering tissue plasminogen activator (tPA), what should the
nurse
perform FIRST?
a. Ask what medications the client is taking
b. Complete the history and health assessment
c. Identify the time of onset of the stroke
d. Determine if the client is scheduled for any surgical procedures - ANSWER-c.
Identify the time of onset of the stroke
The client has presented with a basilar skull fracture. While assessing the client,
the nurse
notes clear drainage from the nose with a "halo sign" and is concerned about a
potential
cerebrospinal fluid (CSF) leakage. What should the nurse do next?
a. Document this as serous drainage and continue to monitor the client
b. Check for the presence of glucose in the drainage and report to the provider
c. Apply an ice pack to the nasal bridge and a large, fluffy dressing.
d. Assist the client in blowing his nose to clear secretions and re-evaluate. -
ANSWER-b. Check for the presence of glucose in the drainage and report to the
provider
, The nurse is discussing different types of anesthesia with a group of nursing
students. The student nurse correctly identifies which type of anesthesia requires
both inhalation and IV administration routes?
a. General
b. Regional
c. Specific
d. Preoperative - ANSWER-a. General
The nurse is evaluating a client with a head injury and finds drainage from the
client's nose and ears. Which of the following is the priority teaching for this
client?
a. Cleanse the ear and nose with a soft cotton tipped swab and hydrogen peroxide
b. Gently suction the nasal cavity to reduce the amount of secretions
c. Wipe the nose or ears, but do not blow the nose or place anything in the ear
d. Place a pressure dressing over the affected areas to reduce leakage. - ANSWER-
c. Wipe the nose or ears, but do not blow the nose or place anything in the ear
The nurse is assisting with the sponge and instrument count in the operating room.
Which operative phase does this occur in?
a. Perioperative phase
b. Preoperative phase
c. Intraoperative phase
d. Postoperative phase - ANSWER-c. Intraoperative phase
A client has been diagnosed with an ischemic stroke. The nurse realizes this client
cannot have fibrinolytic therapy until which vital sign is addressed and treated?
a. Blood pressure of 220/120 mm HG
b. Oxygen saturation of 92%