The PACU nurse will maintain postoperative T and A client in what position?

Correct Answer: B

Rationale: In the post-anesthesia care unit (PACU), maintaining a postoperative tonsillectomy and adenoidectomy (T and A) client in a prone position with the head on a pillow and turned to the side is crucial for several reasons. Placing the client in a prone position helps prevent aspiration of blood or secretions, as gravity aids in drainage. Additionally, this position promotes airway patency by allowing the tongue to fall forward, preventing obstruction. On the other hand, the other options are incorrect for various reasons. Option A, placing the client supine with the neck hyperextended and supported with a pillow, can increase the risk of airway obstruction due to potential obstruction of the pharynx by the tongue. Option C, placing the client in a semi-Fowler's position with the neck flexed, may also lead to airway compromise as neck flexion can obstruct the airway. Option D, placing the client in reverse Trendelenburg with an extended neck, does not provide the optimal positioning for airway management and can increase the risk of aspiration. In an educational context, understanding the rationale behind positioning postoperative clients is essential for nurses working in the PACU. Proper positioning can significantly impact patient outcomes, including airway patency, prevention of complications such as aspiration, and overall patient safety and comfort. Nurses must be knowledgeable about appropriate postoperative positioning techniques to provide high-quality care and ensure positive recovery outcomes for their patients.

Correct Answer: D

Rationale: In radiation therapy, the earliest sign of a skin reaction is pigmentation (Option D). This occurs due to the damage caused to melanocytes in the skin by the radiation. Pigmentation changes are often the first noticeable effect on the skin following radiation exposure. Erythema (Option B) typically occurs after pigmentation changes and is characterized by redness of the skin. Desquamation (Option A) refers to the shedding of the outer layers of the skin and usually occurs as a later stage reaction to radiation. Atrophy (Option C) is the thinning of the skin and is also a delayed effect of radiation exposure. Educationally, understanding the sequence of skin reactions to radiation therapy is crucial for nurses and healthcare providers involved in caring for patients undergoing radiation treatment. Recognizing these signs early can help in providing timely interventions to manage and alleviate the skin reactions, thus improving the patient's overall comfort and treatment experience.

Correct Answer: C

Rationale: In the event of an adverse hemolytic reaction during a blood transfusion, the correct nursing intervention should focus on stopping the infusion, calling the physician, and assessing the client (Option C). This is the correct answer because a hemolytic reaction can be life-threatening and requires immediate action to prevent further harm to the patient. Option A is incorrect because simply slowing the infusion may not be sufficient to address the serious nature of a hemolytic reaction. Calling the physician and assessing the patient are important steps, but stopping the infusion is crucial. Option B is incorrect because sending the remaining blood to the laboratory is not a priority when the client's safety is at risk. Stopping the infusion and assessing the client should take precedence. Option D is incorrect because in the case of a hemolytic reaction, just slowing the infusion and keeping a patent IV line open for medication administration is not enough. The priority is to stop the infusion and address the adverse reaction promptly. From an educational perspective, understanding the importance of immediate action in the face of a potentially life-threatening situation like a hemolytic reaction during a blood transfusion is crucial for nurses. This scenario emphasizes the significance of rapid assessment, critical thinking, and prioritization in providing safe and effective patient care in clinical practice.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Potassium chloride. After surgery, Leda is experiencing symptoms of hypocalcemia, which is characterized by peripheral numbness, tingling, and muscle twitching/spasms. Potassium chloride is administered to treat hypocalcemia because potassium plays a vital role in maintaining proper muscle and nerve function. By administering potassium chloride, the levels of potassium in the body can be restored, helping to alleviate Leda's symptoms. The other options are incorrect for this situation: A) Magnesium sulfate is used to treat magnesium deficiency, not hypocalcemia. B) Calcium gluconate is used to treat calcium deficiencies, but in this case, the symptoms are indicative of low potassium levels, not calcium. C) Potassium iodide is used to treat iodine deficiency and is not relevant to the symptoms described. This educational context highlights the importance of understanding electrolyte imbalances post-surgery and the significance of selecting the appropriate treatment based on the specific electrolyte affected. Nurses must be able to recognize symptoms of electrolyte imbalances and understand the pharmacological interventions required to address them effectively to ensure patient safety and recovery.

Correct Answer: D

Rationale: During the acute phase of a burn, fluid resuscitation is the priority nursing intervention. This phase is characterized by fluid loss and the risk of hypovolemic shock. Administering fluids is crucial to maintain perfusion and prevent complications such as organ failure. While prevention of infection, pain management, and prevention of bleeding are important aspects of burn care, fluid resuscitation takes precedence in the acute phase to stabilize the client's condition and prevent further damage.