What is the most important postoperative instruction that nurse Kate must give a client who has just returned from the operating room after receiving a subarachnoid block?

Correct Answer: D

Rationale: The correct answer is D because after receiving a subarachnoid block, the client should remain supine for the specified time to prevent complications like a sudden drop in blood pressure. This position helps maintain proper blood flow to the brain and spinal cord. A is incorrect because maintaining hydration is important postoperatively. B is incorrect as there is no specific reason to avoid milk products. C is incorrect as blood in urine is not a common complication of a subarachnoid block and would not be the most important instruction at this time.

Correct Answer: C

Rationale: The correct nursing intervention in this scenario is option C: Restricting fluids. In the treatment of SIADH, which is characterized by excessive release of antidiuretic hormone leading to water retention and dilutional hyponatremia, fluid restriction is crucial. By limiting fluid intake, the goal is to help restore a normal balance of fluids and electrolytes in the body. Infusing I.V. fluids rapidly as in option A would worsen the condition by further increasing fluid volume. Encouraging increased oral intake as in option B is contraindicated as it would exacerbate the fluid overload already present in SIADH. Administering glucose-containing I.V. fluids as in option D is not the primary intervention for managing SIADH; instead, fluid restriction is key to correcting the underlying imbalance. In an educational context, understanding the rationale behind each nursing intervention is vital for nurses to provide safe and effective care. By grasping the pathophysiology of conditions like SIADH, nurses can make informed clinical decisions to promote positive patient outcomes. Remembering the specifics of fluid management in SIADH is essential knowledge for nursing practice.

Correct Answer: B

Rationale: The correct answer is B: Pallor, tachycardia, and a sore tongue. In pernicious anemia, the body lacks intrinsic factor needed for vitamin B12 absorption, leading to megaloblastic anemia. Pallor is a common symptom due to decreased red blood cells. Tachycardia occurs as the heart compensates for decreased oxygen-carrying capacity. A sore tongue, known as glossitis, is a classic sign of B12 deficiency. Choices A, C, and D do not align with typical manifestations of pernicious anemia.

Correct Answer: B

Rationale: The correct answer is B because a client with a cast on the right leg reporting a "funny feeling" could indicate a potential circulation or nerve issue, which requires immediate attention to prevent complications. It is important to prioritize urgent physical concerns over other symptoms like itching, nausea, or trouble sleeping. The other options, A, C, and D, are important but not as urgent as the potential complications associated with impaired circulation or nerve function in a client with a leg cast.

Correct Answer: A

Rationale: The correct answer is A: Encourage the client to perform pursed lip breathing. This is the appropriate step because the client with emphysema showing restlessness and confusion may be experiencing hypoxia. Pursed lip breathing helps improve oxygenation by slowing down breathing and facilitating better gas exchange. Checking the client's temperature (B) is not the priority in this situation. Assessing the client's potassium level (C) may be important but not the immediate step for a client showing signs of hypoxia. Increasing the client's oxygen flow rate (D) can be considered after assessing the client's response to pursed lip breathing.