The nurse is assisting with the care of a client.

Exhibits

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client. There are six tabs that contain separate categories of data.)

Provide the client with ice chips

Discontinue nasogastric tube

Reinforce preoperative teaching

Start the prescribed antibiotics

Answer and Explanation

The Correct Answer is C

A. Provide the client with ice chips: The client is on NPO status in preparation for surgery. Offering ice chips could increase the risk of aspiration or delay surgical procedures, so this action is not appropriate at this time.

B. Discontinue nasogastric tube: The NG tube is necessary to decompress the stomach and relieve nausea from the small-bowel obstruction. Removing it before surgery or resolution of obstruction could worsen vomiting and distention, so discontinuation is not indicated.

C. Reinforce preoperative teaching: Preoperative teaching helps reduce anxiety, improve cooperation, and prepare the client for what to expect during and after the exploratory laparotomy. This action is appropriate and supports client safety and understanding.

D. Start the prescribed antibiotic: The prescription for Cefazolin is 2 g IV and is ordered "on call for surgery." This means the antibiotic should be administered just before the surgical procedure begins, to ensure therapeutic levels are present in the bloodstream when the incision is made.

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Correct Answer is ["A","C","E"]

Explanation

A. Potassium: Spironolactone is a potassium-sparing diuretic. The client’s potassium level of 5.2 mEq/L is above normal, increasing the risk of hyperkalemia. Administering spironolactone in this context is contraindicated until potassium is corrected.

B. BUN: Although the BUN is elevated, indicating possible dehydration or renal impairment, it is not an absolute contraindication. Careful monitoring and dose adjustment may be necessary, but it does not automatically preclude spironolactone use.

C. Allergy: The client has a sulfonamide allergy. Spironolactone contains a sulfonamide group, which can trigger hypersensitivity reactions. This allergy is a clear contraindication to administering the medication.

D. Respiratory rate: The respiratory rate is within a reasonable range and does not affect the safety or efficacy of spironolactone. It is not a contraindication.

E. Creatinine: The elevated creatinine (1.7 mg/dL) indicates impaired renal function. Spironolactone can worsen hyperkalemia and fluid retention in clients with kidney dysfunction, making significant renal impairment a contraindication for its use.

A. Encourage the client to use a straw to sip cool liquids. B. Place the client in a semi-Fowler's position. C. Encourage the client to cough. D. Obtain the client's peak expiratory flow volume.

Correct Answer is B

Explanation

A. Encourage the client to use a straw to sip cool liquids: Using a straw can increase the risk of trauma to the surgical site, potentially causing bleeding. After a tonsillectomy, clients should sip liquids directly from a cup to protect the tonsillar area.

B. Place the client in a semi-Fowler's position: Semi-Fowler’s position promotes optimal lung expansion, improves oxygenation, and helps prevent airway obstruction. This position supports respiratory function and is appropriate for a client with an SpO2 of 93%.

C. Encourage the client to cough: Coughing can strain the surgical site and increase the risk of postoperative bleeding. Gentle deep breathing is preferred, while forceful coughing should be avoided until healing progresses.

D. Obtain the client's peak expiratory flow volume: Peak expiratory flow measurement is not routinely indicated after a tonsillectomy. Focus should be on monitoring oxygenation, airway patency, and signs of respiratory distress rather than lung function testing.

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The nurse is assisting with the care of a client. Exhibits Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client. There are six tabs that contain separate categories of data.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has a new prescription for spironolactone. Which of the following client findings should the nurse identify as a contraindication to the administration of spironolactone? Select the 3 findings the nurse should identify as a contraindication.

Correct Answer is ["A","C","E"]

Explanation

A nurse is assisting in the care of a client following a tonsillectomy who is alert and has an SpO2 of 93% on room air. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

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The nurse is assisting with the care of a client.

Exhibits

Which of the following actions should the nurse assist with? (Click on the exhibit tabs for additional information about the client. There are six tabs that contain separate categories of data.)