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Questions 158

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Question 1 of 5

A 25-year-old client is admitted for a tonsillectomy. She tells the nurse that she has had episodes of muscle cramps, weakness, and unexplained temperature elevation. Many years ago her father died shortly after surgery after developing a high fever. She further tells the nurse that her surgeon is having her take dantrolene sodium (Dantrium) prophylactically prior to her tonsillectomy. Dantrolene sodium is ordered preoperatively to reduce the risk or prevent:

Correct Answer: B

Rationale: Dantrolene sodium is a peripheral skeletal muscle relaxant and would have no effect on a postoperative infection. Dantrolene sodium is indicated prophylactically for clients with malignant hyperthermia or with a family history of the disorder. The mortality rate for malignant hyperthermia is high. Neuroleptic malignant syndrome is an exercise-induced muscle pain and spasm and is unrelated to malignant hyperthermia.

Question 2 of 5

The client is admitted with a diagnosis of acute pancreatitis. Which position is most comfortable for the client?

Correct Answer: D

Rationale: Side-lying with knees flexed reduces pressure on the inflamed pancreas, providing comfort in acute pancreatitis. Supine, prone, and Fowler’s positions may increase discomfort.

Question 3 of 5

The nurse is preparing to administer regular insulin by continuous IV infusion to a client with diabetic ketoacidosis. The nurse should:

Correct Answer: D

Rationale: Regular insulin for IV infusion should be diluted in normal saline to ensure compatibility and prevent adsorption to IV tubing. Dextrose is inappropriate during DKA, and flushing with insulin wastes medication.

Question 4 of 5

A client admitted with a diagnosis of possible myocardial infarction is admitted to the unit from the emergency room. The nurse's first action when admitting the client will be to:

Correct Answer: B

Rationale: Obtaining vital signs is important after connecting the client to the monitor because vital signs should be stable before the client is discharged from the emergency room. All are important, but the first priority is to monitor the client's rhythm. If the client is in severe pain, pain medication should be given after connecting him to the monitor and obtaining vital signs. Completion of the history profile is the least important of the nursing actions.

Question 5 of 5

During morning assessments, the nurse finds that a client's nephrostomy tube has been clamped. The nurse's first action should be to:

Correct Answer: C

Rationale: Unclamping the nephrostomy tube is the priority to restore urine flow and prevent complications like hydronephrosis or infection.

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