The nurse is preparing a client with systemic lupus erythematosus (SLE) for discharge. Which instruction should the nurse include in the teaching plan?

Correct Answer: C

Rationale: Monitoring body temperature is important in clients with systemic lupus erythematosus (SLE) because fever can indicate an infection or a disease flare-up. Clients with SLE are at higher risk of infections due to their compromised immune system, and fever can be a sign of an underlying issue that needs prompt attention. It is essential for the nurse to educate the client about monitoring body temperature regularly and seeking medical advice if there is a sudden increase in temperature.

Correct Answer: B

Rationale: Special positioning is required for a spinal (sub-arachnoid) block to prevent cerebrospinal fluid (CSF) leakage. The client is usually positioned in either a sitting or lateral decubitus position to allow for easier access to the spinal canal and ensure proper administration of the anesthesia. Maintaining the correct positioning helps to minimize the risk of CSF leakage, which can result in headaches and potential complications postoperatively. By positioning the client appropriately during the procedure, healthcare providers can optimize the effectiveness of the spinal block while reducing the risk of adverse effects.

Correct Answer: A

Rationale: In the preoperative phase, one of the key roles of a nurse in patient care is to obtain preoperative orders. This involves ensuring that all necessary tests, medications, and procedures are in place before the surgery is performed. By obtaining preoperative orders, the nurse ensures that the patient is adequately prepared for the surgical procedure and that any potential risks or complications are minimized. This role requires attention to detail, clear communication with the healthcare team, and a thorough understanding of the patient's individual needs and medical history.

Correct Answer: C

Rationale: Newborn infants born to mothers who are addicted to drugs are at risk for neonatal abstinence syndrome (NAS) due to drug withdrawal. Lethargy is a common finding in newborns with NAS. This is characterized by excessive sleepiness, decreased responsiveness, and lack of energy or enthusiasm for activities. Lethargy is often seen as a result of the withdrawal symptoms experienced by the newborn due to exposure to drugs in utero. It is important for the nurse to monitor the newborn closely for signs of withdrawal and provide appropriate care and interventions to manage NAS symptoms.

Correct Answer: B

Rationale: Severe and extensive hemolysis can lead to the destruction of a large number of red blood cells, causing a significant release of hemoglobin into the bloodstream. This excessive release of hemoglobin can overwhelm the body's ability to clear it, leading to the accumulation of toxic byproducts such as free hemoglobin and heme. These byproducts can lead to various complications, one of which is the potential for causing shock. Shock is a life-threatening condition characterized by inadequate tissue perfusion and oxygen delivery to vital organs due to a systemic vascular response to the circulating toxins and byproducts of hemolysis. It is a severe consequence of extensive hemolysis and requires immediate medical intervention to stabilize the patient.