A nurse is receiving a client from the post anesthesia unit after a colon resection. What is the first observation the nurse should perform?
Client’s wound dressing is dry.
Client is awake and oriented.
Client is breathing.
Client’s foley catheter is draining.
The Correct Answer is C
The first observation the nurse should perform for a client who is receiving from the post anesthesia unit after a colon resection is to assess the patency of the airway and respiratory function.
This is because the airway is the most vital for the survival of the client and any compromise can lead to hypoxia and death.
The nurse should then take vital signs, check the wound dressing, and assess the foley catheter drainage.
Choice A is wrong because the client’s wound dressing is not as important as the airway and can be checked later.
Choice B is wrong because the client’s level of consciousness may be affected by the anesthesia and is not a priority over the airway.
Choice D is wrong because the client’s foley catheter drainage is not a critical observation and can be monitored later.
Normal ranges for respiratory rate are 12 to 20 breaths per minute for adults, oxygen saturation is 95% to 100%, and blood pressure is 120/80 mmHg for healthy individuals.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","E"]
Explanation
These interventions are based on the principles of sleep hygiene and cognitive behavioral therapy for insomnia (CBT-I), which are evidence-based strategies to promote better sleep.
Choice A is wrong because alcohol can disrupt sleep quality and cause frequent awakenings during the night. It can also interfere with the normal sleep cycle and reduce REM sleep.
Choice D is wrong because reading a book 30 minutes before bedtime can be stimulating and make it harder to fall asleep. It can also violate the stimulus control therapy, which aims to associate the bed only with sleep and sex and avoid any other activities that may keep the mind alert.
Some additional sentences are:
- Normal ranges for sleep vary depending on age, lifestyle, and individual factors, but generally adul,ts need about 7 to 9 hours of sleep per night.
- Insomnia is a common sleep disorder that affects about 10% to 30% of adults and can have negative impacts on physical and mental health, as well as quality of life.
- If insomnia persists despite following these interventions, it is advisable to consult a doctor or a sleep specialist for further evaluation and treatment options.
Correct Answer is A
Explanation
This statement suggests that the client needs further teaching because haloperidol is a medication that needs to be taken regularly and consistently to prevent relapse of symptoms related to schizophrenia. Stopping the medication abruptly can cause withdrawal effects and worsen the condition.
Choice B is wrong because it shows that the client understands the potential interaction between alcohol and haloperidol, which can increase the risk of sedation, drowsiness, and low blood pressure.
Choice C is wrong because it indicates that the client has realistic expectations about the onset of action of haloperidol, which can take several days or weeks to show improvement of symptoms.
Choice D is wrong because it demonstrates that the client is aware of the possible side effect of photosensitivity caused by haloperidol, which can make the skin more prone to sunburn and damage.
Haloperidol is an antipsychotic drug that works by blocking dopamine receptors in the brain. It is used to treat symptoms such as hallucinations, delusions, paranoia, and disorganized thinking in schizophrenia and other psychotic disorders. The normal dosage range for haloperidol is 0.5 to 20 mg per day, depending on the severity of the condition and the response to treatment. Some of the common side effects of haloperidol include extrapyramidal symptoms (EPS), such as muscle stiffness, tremors, restlessness, and abnormal movements; neuroleptic malignant syndrome (NMS), which is a rare but serious condition characterized by fever, muscle rigidity, altered mental status, and autonomic instability; and tardive dyskinesia (TD), which is a chronic movement disorder that involves involuntary movements of the tongue, lips, face, and limbs. Haloperidol can also cause weight gain, dry mouth, blurred vision, constipation, dizziness, insomnia, and sexual dysfunction.
Haloperidol should be used with caution in patients with cardiovascular disease, liver disease, seizure disorder, diabetes mellitus, thyroid dysfunction
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