A client requires minor surgery for removal of a basal cell tumor. The anesthesiologist administers the anesthetic ketamine hydrochloride (Ketalar), 60g IV. After Ketamine administration, the nurse should monitor the client for:

Correct Answer: A

Rationale: Ketamine hydrochloride (Ketalar) is a dissociative anesthetic that can cause muscle rigidity and spasms as a side effect. This is known as a dose-dependent reaction to ketamine administration. Monitoring for muscle rigidity and spasms is important to ensure the client's safety and to provide appropriate management if this adverse effect occurs. It is essential for the nurse to closely observe the client for any signs of muscle rigidity and spasms after the administration of ketamine.

Correct Answer: B

Rationale: Eating a diet high in protein and calories to optimize tissue repair would be the most appropriate instruction to suggest in this scenario. Dysphagia (difficulty swallowing) and skin texture changes can occur as side effects of radiation therapy for breast cancer. Protein is essential for tissue repair, while calories provide the necessary energy for the body to heal. By consuming a diet high in protein and calories, the client can support their body's healing process, minimize the risk of complications, and promote healing at the radiation site. It is important to note that maintaining proper nutrition is crucial during cancer treatment to support overall health and well-being.

Correct Answer: A

Rationale: Applying zinc oxide to the surrounding skin can help protect it from becoming macerated due to irritating drainage or wound compresses. Zinc oxide acts as a barrier that helps prevent moisture from affecting the skin, thus reducing the risk of maceration. It provides a protective layer and promotes healing by keeping the affected area dry and free from further irritation. It is an effective intervention to maintain skin integrity and promote optimal wound healing in clients with a breast abscess.

Correct Answer: B

Rationale: Furosemide IV is a diuretic medication commonly used to treat conditions such as pulmonary edema. In the case of pulmonary edema, the excess fluid accumulates in the lungs, leading to symptoms such as difficulty breathing, wheezing, and the production of pink, frothy sputum. The presence of pink, frothy sputum is a classic sign of pulmonary edema and indicates the presence of fluid in the airways. Therefore, the nurse would evaluate the effectiveness of furosemide IV treatment by monitoring the resolution of this specific symptom, as it indicates improvement in the underlying condition of pulmonary edema.

Correct Answer: C

Rationale: The correct statement indicating the patient has a good understanding of the treatment regimen is statement C: "I'll take my medication in the morning, every morning." This statement shows that the patient acknowledges the importance of taking their prescribed bumetanide (Bumex) every morning as directed. Consistency in taking the medication as prescribed is crucial for the effective control of hypertension. Statements A and B are unrelated to the treatment regimen and do not address medication adherence. Statement D reflects a misconception that medication can be stopped once blood pressure decreases, which is inaccurate and potentially harmful.