The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Place a warm blanket on the client.

Administer IV fluids per protocol.

Review the medication administration record.

Check the urinary catheter r an occlusion.

Answer and Explanation

The Correct Answer is B

A. Place a warm blanket on the client: Providing warmth may improve comfort temporarily but does not address the underlying cause of the client’s cool, moist hands, prolonged capillary refill, or low urine output, which suggest possible hypovolemia or shock.

B. Administer IV fluids per protocol: The client’s signs restlessness, cool clammy skin, prolonged capillary refill, and low urine output indicate hypoperfusion likely due to fluid deficit. Administering IV fluids promptly helps restore circulating volume and tissue perfusion.

C. Review the medication administration record: While medication review is important for overall safety, it does not address the immediate risk of hypovolemic shock or low urine output in this client.

D. Check the urinary catheter for an occlusion: Although checking for blockage is reasonable if a catheter is present, the client’s overall clinical presentation points to systemic hypovolemia rather than a localized urinary obstruction.

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Correct Answer is D

Explanation

A. Iodine: An iodine allergy is more relevant for clients receiving contrast media or iodine-based antiseptics, not dorzolamide. Dorzolamide is a carbonic anhydrase inhibitor, and its risk profile is not associated with iodine sensitivity.

B. Latex: Latex allergy is an important consideration in nursing care, particularly regarding equipment and supply use. However, dorzolamide as an ophthalmic preparation does not contain latex, so this allergy does not directly influence the safety of administering the drug.

C. Penicillin: Penicillin allergy is significant for antibiotics, but dorzolamide is not a beta-lactam or related medication. There is no cross-reactivity between penicillin and carbonic anhydrase inhibitors, making this allergy less concerning for this prescription.

D. Sulfonamide: Dorzolamide contains a sulfonamide component, and clients with a sulfonamide allergy are at risk for hypersensitivity reactions such as rash, conjunctivitis, or even systemic effects. Reviewing the medical record for a sulfonamide allergy is essential before administration to prevent serious complications.

A. Encourage the wife to voice her feelings about having a husband with Parkinson's disease. B. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism. C. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease. D. Compile a list of alternative medications that are effective in curing Parkinson's disease.

Correct Answer is C

Explanation

A. Encourage the wife to voice her feelings about having a husband with Parkinson's disease: While it is important to provide emotional support and encourage expression of feelings, this does not address her specific question about alternative or complementary cures.

B. Tell the wife that her husband's neurologist would know more about alternative treatments to cure Parkinsonism: Referring to the neurologist may seem appropriate, but it avoids answering the wife’s concern directly.

C. Explain that there are no known conventional, alternative, or complimentary therapies that cure Parkinson's disease: Parkinson’s is a progressive neurodegenerative disorder, and while medications and some therapies can manage symptoms, no cure currently exists. This response provides clear, evidence-based information and directly answers the wife’s question.

D. Compile a list of alternative medications that are effective in curing Parkinson's disease: No alternative or complementary medications have been proven to cure Parkinson’s disease. Providing such a list would give false hope and misinformation.

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The nurse is caring for a postoperative client who has a saline lock and minimal urine in the drainage bag, who appears anxious and restless. The nurse notices that the client's hands are cool and moist, with prolonged capillary refill. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client diagnosed with glaucoma receives a new prescription for dorzolamide. Prior to administering the medication, the nurse should review the electronic medical record for which allergy?

Correct Answer is D

Explanation

The wife of a newly diagnosed client with Parkinson's disease asks the nurse if alternative or complimentary medical therapies might cure the disease. Which response should the nurse provide?

Correct Answer is C

Explanation

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