Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

Remove the transdermal patch until the vomiting subsides.

Reposition the transdermal patch to the client's trunk.

Explain that this is a side effect of the medication in the patch.

Notify the client's healthcare provider of the vomiting.

Answer and Explanation

The Correct Answer is D

A.   Removing the scopolamine patch is not indicated without consulting the healthcare provider.
B.   Repositioning the patch is not necessary as it is properly placed for its intended effect.
C.   While nausea and vomiting are potential side effects of scopolamine, it's important to notify the healthcare provider to determine the appropriate next steps.
D.   Notifying the healthcare provider allows for further evaluation and possible adjustment of the client's postoperative antiemetic regimen.

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Correct Answer is B

Explanation

A. A toileting schedule is unnecessary for an anuric client as they do not produce urine.
B. Anemia is a common complication of chronic kidney disease due to reduced erythropoietin production, so monitoring for signs of anemia is important.
C. High potassium foods should be avoided as impaired kidney function can lead to hyperkalemia.
D. While perineal skin care is important, it is not as critical as monitoring for anemia in this context.

A. Institute contact precautions for staff and visitors. B. Explain the purpose of a low bacteria diet. C. Monitor the client's white blood cell count. D. Send wound drainage for culture and sensitivity. E. Use standard precautions and wear a mask.

Correct Answer is ["A","C","D"]

Explanation

A. Contact precautions are essential to prevent the spread of MRSA to other patients and healthcare workers. This includes wearing gloves and gowns when entering the patient's room.

B. A low bacteria diet is not specifically relevant to managing MRSA and is more applicable to neutropenic patients.
C. Monitoring the white blood cell count helps in assessing the client's response to infection and identifying any potential systemic involvement.
D. Sending wound drainage for culture and sensitivity is crucial for identifying the specific strain of MRSA and determining the most effective antibiotic treatment.
E. Standard precautions are always necessary, but a mask is not required unless there is a risk of splashing or the patient has a respiratory infection.

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Four hours after surgery, a client reports nausea and begins to vomit. The nurse notes that the client has a scopolamine transdermal patch applied behind the ear. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is planning care for a client with chronic kidney disease who is a resident at a long-term nursing facility. The client is anuric and has hemodialysis 3 times a week. Which intervention should the nurse include in the client's plan of care?

Correct Answer is B

Explanation

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). What nursing intervention(s) should the nurse include in the plan of care? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

The psychiatric nurse is caring for clients on an adolescent unit. Which client requires the nurse's immediate attention?

Exhibits Click to select the 5 most important nursing interventions for postoperative client care.

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