The LPN is caring for a patient in the preoperative period who, even after verbalizing concerns and having questions answered, states, "I know I am not going to wake up after surgery." Which of the following actions should the nurse take?

Correct Answer: C

Rationale: The correct action for the LPN to take in this situation is to inform the registered nurse. The patient's statement indicates a high level of fear and anxiety about the surgery and their potential outcome. It is important to involve the registered nurse, who can provide further assessment, support, and interventions to address the patient's concerns appropriately. Simply reassuring the patient or providing statistics about national surgery death rates may not address the underlying fear and may require additional support and intervention. Asking the family to comfort the patient may not be the most appropriate immediate action as the patient's concerns are specific and may require professional support. Bringing the registered nurse into the situation allows for a comprehensive approach to addressing the patient's emotional needs before the surgery.

Correct Answer: A

Rationale: Furosemide is a loop diuretic commonly used to help the body get rid of excess salt and water through increased urine output. By inhibiting the reabsorption of sodium and chloride in the loop of Henle in the kidneys, furosemide promotes the excretion of water, sodium, chloride, and other electrolytes. Therefore, the nurse would evaluate the medication as effective if the patient experiences increased urine output, as it indicates that the furosemide is working to eliminate excess fluids from the body.

Correct Answer: A

Rationale: Enalapril maleate (Vasotec) is an angiotensin-converting enzyme (ACE) inhibitor. The main action of ACE inhibitors like enalapril is to decrease the levels of angiotensin II in the body. Angiotensin II is a potent vasoconstrictor that plays a role in regulating blood pressure, stimulating aldosterone secretion, and promoting sodium and water retention. By inhibiting the conversion of angiotensin I to angiotensin II, enalapril reduces vasoconstriction and aldosterone secretion, leading to vasodilation, decreased blood pressure, and ultimately decreased levels of angiotensin II. This mechanism allows for the dilation of arterioles and veins, reduction in cardiac afterload, and ultimately decreases the workload of the heart.

Correct Answer: A

Rationale: A decreasing level of consciousness is a symptom often associated with increased intracranial pressure (ICP). When the pressure inside the skull rises, it can compress and damage the brain, leading to a deterioration in consciousness. Common causes of increased ICP include traumatic brain injury, brain tumors, and infections. As ICP continues to rise, it can result in serious consequences such as brain herniation, which can be life-threatening if not promptly managed. Therefore, a decreasing level of consciousness should raise concerns about increased ICP and warrant immediate medical evaluation and intervention.

Correct Answer: C

Rationale: The sudden severe headache and nasal congestion in a client with a spinal cord injury at the level of T3, along with flushed skin, goose bumps, and potentially increased blood pressure due to autonomic dysreflexia. This is a medical emergency that requires immediate intervention from a healthcare provider. Calling the physician ensures prompt assessment and treatment to prevent further complications associated with autonomic dysreflexia, such as hypertensive crisis, seizures, or stroke. It is important to address this situation promptly to prevent any serious consequences for the client's health.