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 C

Explanation

A. Social interaction can help, but it is not the most effective immediate strategy for managing anxiety.
B. Reflecting on the reasons for anxiety is useful for long-term management but not for immediate relief.
C. Muscle relaxation techniques are an effective and immediate method for reducing anxiety symptoms.
D. Listening to music can help but is less effective than targeted relaxation techniques.

A. Determine apical pulse rate and rhythm. B. Observe color and amount of urine. C. Assess strength of deep tendon reflexes. D. Compare muscle strength bilaterally

Correct Answer is A

Explanation

A. An ionized calcium level significantly above the reference range can lead to cardiac dysrhythmias and requires immediate attention to assess cardiac function.
B. While urine output and characteristics are important indicators of renal function, cardiac assessment takes priority due to the potential cardiac effects of hypercalcemia.
C. Assessment of deep tendon reflexes is relevant since hypercalcemia can lead to muscle weakness and diminished reflexes. However, this should be done after assessing for any cardiac dysrhythmias.
D. Comparing muscle strength bilaterally is important for assessing neurological integrity but is not the priority when hypercalcemia is suspected.

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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 providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

When assessing a client with an ionized calcium level of 17 mg/dL (4.25 mmol/L), which intervention is most important for the nurse to implement? Reference Range lonized Calcium [Adult 4.6 to 5.1 mg/dL (1.15 to 1.35 mmol/L)]

Correct Answer is A

Explanation

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