Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires immediate action by the nurse?
a. Only continuous IV opioids have been ordered.
b. The patient does not respond to verbal stimulation.
c. There is no cough or gag when the patient is suctioned.
d. The patient's oxygen saturation fluctuates between 90% to 93%.
ANS: A
Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The oxygen saturation is adequate.
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The nurse is discussing genetic referral with the parents of children being seen in the pediatric clinic. The child who would benefit from a genetic referral is the child whose family has a history of:
1. Prominent epicanthal folds, resonant lungs, or absent tinnitus in Asian families. 2. Broad face, lower-extremity lichenification, or spider angiomas. 3. Normocephalic head, euthyroid, or five digits per extremity. 4. Cleft lip and/or cleft palate, diaphragmatic hernia, or cataract.
The nurse is working in an outpatient studies unit administering neurologic tests. The client is surprised that paste is used to secure an electroencephalogram and asks how it will be removed from the hair. The nurse is most correct to state which?
A) The paste is removed with acetone. B) The paste is removed with a special soap. C) The paste is removed with standard shampoo. D) The paste is removed by flushing with warm water.
During assessment of hydration status, the client tells the nurse that she usually drinks 3 quarts of liquids each day. Which question by the nurse is best?
a. "Do you usually drink liquids that are hot or cold?" b. "How much salt do you add to your food?" c. "What kinds of liquids do you usually drink?" d. "Do you drink fluids with meals or be-tween meals?"
Which breech presentation should the nurse recognize as being favorable for an external cephalic version?
a. 36-week gestation with low-lying placenta b. 38-week gestation with one previous cesarean c. 37-week gestation with fetal weight of 7 pounds d. 40-week gestation with several uterine fibroids