The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?

Call a rapid response for more assistance

Administer naloxone 0.4 mg SQ and reassess

Check the temperature and apply warmed blankets

Encourage the client to take deep breaths

Answer and Explanation

The Correct Answer is D

A. Calling a rapid response may be necessary if the client's condition deteriorates, but it is not the immediate priority in this scenario where the client is still able to be aroused.
B. Administering naloxone is appropriate if there is suspicion of opioid overdose; however, the priority is to address the low oxygen saturation first with non-invasive measures.
C. Checking the temperature and applying warmed blankets may be important, but the immediate concern is the low oxygen saturation.
D. Encouraging the client to take deep breaths is the most appropriate immediate action to improve oxygen saturation levels and enhance ventilation, as the client is in a post-anesthesia state where respiratory depression can occur.

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Correct Answer is C

Explanation

A. Using a commercial medicine to remove a corn is not recommended, as it can cause skin damage and infection; diabetic clients should seek professional care for such issues.
B. Soaking feet daily in cool water can lead to skin maceration and should generally be avoided; it is better to wash and dry feet gently.
C. Utilizing a mirror to examine the soles of the feet indicates proper awareness and self-care, as diabetic clients need to monitor for any injuries or changes that could lead to complications.
D. Cutting nails in a concave manner is incorrect; nails should be cut straight across to prevent ingrown toenails.

A. "You may feel some slight tingling in your lower extremities." B. "Paresthesia may occur because of the procedure, but it is only temporary." C. "The needle is placed between the vertebrae, but below where the spinal cord ends." D. "You should report any numbness during the procedure to the physician immediately."

Correct Answer is C

Explanation

A. Informing the patient about possible tingling is not as reassuring and does not directly address their concern about spinal cord damage.
B. While paresthesia can occur, focusing on temporary effects might not alleviate the patient’s primary concern about spinal cord injury.
C. Explaining that the needle is placed below where the spinal cord ends directly addresses the patient’s anxiety about potential damage, providing clarity and reassurance about the safety of the procedure.
D. While it is important for patients to report numbness, this response does not reassure them about the procedure's safety and may increase their anxiety.

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The nurse is caring for a client who had a bowel resection for colon cancer. The vital signs were stable during surgery. While in the post-anesthesia care unit (PACU) the client is sleepy but awakens easily. The pulse ox is 88%. What would be the priority action by the nurse?

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Naxlex Comprehensive Predictor Exams

The nurse teaches a diabetic client how to perform foot care. Which action by the client would indicate that they can correctly perform foot care?

Correct Answer is C

Explanation

The nurse is caring for a patient who is about to have a lumbar puncture to obtain cerebrospinal fluid for lab analysis. The patient is anxious about damage to the spinal cord. What is the best response by the nurse?

Correct Answer is C

Explanation

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