Question

A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

Answer 1

Correct Answers:

"Do you have difficulty staying awake when you are driving?"

Rationale :

😴 The highest priority is assessing whether insomnia is creating an immediate safety risk, particularly while the client is driving.

😴 Excessive daytime sleepiness can impair reaction time, concentration, judgment, and alertness, increasing the risk for motor vehicle crashes.

😴 Difficulty staying awake while driving indicates that the sleep disturbance is affecting functioning in a potentially life-threatening way.

😴 Safety concerns take priority over collecting additional information about the cause, duration, or routine associated with insomnia.

😴 Therefore, asking about drowsy driving is the priority because it identifies whether urgent measures are needed to prevent injury.

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Answer 2

Correct Answers:

"I watch television until I fall asleep at night."

Rationale :

📺 Watching television in bed is inconsistent with good sleep hygiene because the bed should primarily be associated with sleep and relaxation.

📺 Light and mental stimulation from television can delay the onset of sleep and interfere with normal circadian rhythms.

📺 Clients should establish a calm bedtime routine and reduce exposure to stimulating screens before attempting to sleep.

📺 If unable to sleep, the client should engage in a quiet activity outside the bed and return when sleepy rather than remain stimulated in bed.

📺 Therefore, relying on television to fall asleep indicates that the client needs additional teaching about healthy sleep habits.

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Answer 3

Correct Answers:

Obstructive sleep apnea

Rationale :

🫁 Obstructive sleep apnea (OSA) increases postoperative risk because sedatives, anesthetics, and opioid analgesics can further depress respiration and reduce upper-airway muscle tone.

🫁 Clients with OSA are at increased risk for airway obstruction, hypoxemia, apnea, respiratory depression, and postoperative cardiopulmonary complications.

🫁 Careful airway assessment and postoperative respiratory monitoring are particularly important after general anesthesia.

🫁 The healthcare team should also determine whether the client normally uses continuous positive airway pressure (CPAP) and ensure appropriate postoperative use when prescribed.

🫁 Therefore, a history of OSA is a significant preoperative finding because anesthesia and analgesia can worsen underlying airway obstruction.

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Answer 4

Correct Answers:

Tachycardia
Tachypnea
Muscular rigidity

Rationale :

Tachycardia

🔥 Tachycardia is an early manifestation of malignant hyperthermia caused by a severe hypermetabolic response in skeletal muscle.

🔥 Excessive calcium release within muscle cells dramatically increases metabolic activity and oxygen consumption.

🔥 Sympathetic stimulation and rising carbon dioxide levels contribute to a rapidly increasing heart rate.

🔥 Tachycardia may appear before a dramatic rise in body temperature, making it an important early warning sign.

🔥 Therefore, unexplained tachycardia during or shortly after anesthesia should raise concern for malignant hyperthermia.

Tachypnea

🔥 Tachypnea can occur because malignant hyperthermia causes increased carbon dioxide production and metabolic acidosis.

🔥 The body attempts to compensate by increasing ventilation to remove excess carbon dioxide.

🔥 Rising end-tidal carbon dioxide despite adequate ventilation is often one of the earliest anesthesia-related clues.

🔥 Respiratory changes can develop rapidly as the hypermetabolic crisis progresses.

🔥 Therefore, rapid breathing is consistent with the physiologic response to malignant hyperthermia.

Muscular rigidity

🔥 Generalized muscular rigidity, especially masseter muscle rigidity, is a classic manifestation of malignant hyperthermia.

🔥 Abnormal calcium release causes sustained skeletal-muscle contraction and prevents normal muscle relaxation.

🔥 Continuous contraction generates enormous amounts of heat, carbon dioxide, and lactic acid.

🔥 Muscle rigidity may be accompanied by hyperkalemia and muscle breakdown as the crisis progresses.

🔥 Therefore, unexplained muscular rigidity following exposure to triggering anesthetic agents is a major warning sign.

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Answer 5

Correct Answers:

Frequent falls

Rationale :

🧍 Vertigo causes a sensation of spinning or disequilibrium that can impair balance and safe ambulation.

🧍 Orthostatic hypotension can cause dizziness, weakness, blurred vision, or syncope when the client changes position.

🧍 Postoperative medications, pain, weakness, and residual anesthesia can further increase instability.

🧍 The nurse should assist with position changes, dangle the client before standing, assess blood pressure when indicated, and provide supervised ambulation.

🧍 Therefore, the combination of vertigo and orthostatic hypotension places the client at especially high risk for falls and injury.

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Answer 6

Correct Answers:

0.9% sodium chloride (normal saline)
Lactated Ringer's solution

Rationale :

0.9% sodium chloride (normal saline)

💧 0.9% sodium chloride is an isotonic crystalloid that expands the intravascular and extracellular fluid compartments.

💧 It can be administered rapidly during initial resuscitation for hypovolemia and septic shock to improve circulating volume and tissue perfusion.

💧 Normal saline does not initially cause significant fluid shifts into or out of cells because its tonicity approximates plasma.

💧 Large-volume administration should still be monitored because excessive chloride can contribute to hyperchloremic metabolic acidosis.

💧 Therefore, normal saline is an appropriate isotonic crystalloid for rapid intravascular volume replacement.

Lactated Ringer's solution

💧 Lactated Ringer's solution is a balanced isotonic crystalloid widely used for fluid resuscitation in shock and severe volume depletion.

💧 It contains sodium, chloride, potassium, calcium, and lactate in concentrations designed to approximate extracellular fluid.

💧 The solution effectively increases circulating intravascular volume and supports perfusion during septic shock.

💧 Balanced crystalloids such as Lactated Ringer's may reduce the chloride load associated with large volumes of normal saline.

💧 Therefore, Lactated Ringer's is an appropriate choice for initial fluid resuscitation of a severely hypovolemic septic client.

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Answer 7

Correct Answers:

Hallucinations at the onset of sleep
Sudden attacks of sleep

Rationale :

Hallucinations at the onset of sleep

💤 Clients with narcolepsy may experience hypnagogic hallucinations, which are vivid dream-like experiences occurring as they fall asleep.

💤 These hallucinations are related to abnormal intrusion of REM-sleep phenomena into wakefulness or sleep transitions.

💤 They may be visual, auditory, or tactile and can feel extremely realistic to the client.

💤 Narcolepsy may also involve sleep paralysis, fragmented nighttime sleep, and cataplexy.

💤 Therefore, hallucinations occurring at sleep onset are a characteristic finding associated with narcolepsy.

Sudden attacks of sleep

💤 Narcolepsy is characterized by excessive daytime sleepiness and sudden uncontrollable episodes of sleep.

💤 Sleep attacks can occur during routine activities such as talking, eating, reading, working, or driving.

💤 These episodes may last from a few minutes to longer periods and can interfere significantly with daily functioning and safety.

💤 Clients often describe an irresistible urge to sleep despite having obtained nighttime rest.

💤 Therefore, sudden sleep attacks are one of the hallmark clinical manifestations of narcolepsy.

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Answer 8

Correct Answers:

250

Rationale :

✔️Formula

🔶mL/hr = total volume ÷ total infusion time in hours.

🔶2,000 mL ÷ 8 hr.

🔶250 mL/hr

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Answer 9

Correct Answers:

Prepare to admin dantrolene promptly if malignant hyperthermia symptoms develop.
Communicate the patient's risk of malignant hyperthermia to the surgical and anesthesia teams.
Assess and document detailed family history of malignant hyperthermia prior to surgery.
Place an allergy or alert band on the patient indicating susceptibility to malignant hyperthermia.

Rationale :

Prepare to administer dantrolene promptly if malignant hyperthermia symptoms develop

🧯 Dantrolene is the specific medication used to treat a malignant hyperthermia crisis because it reduces abnormal calcium release from skeletal muscle.

🧯 Prompt administration helps decrease muscle contraction, heat production, hypermetabolism, and associated metabolic complications.

🧯 Dantrolene must be readily available wherever triggering anesthetic agents are administered.

🧯 Treatment is most effective when initiated rapidly at the first signs of malignant hyperthermia.

🧯 Therefore, ensuring immediate access to dantrolene is essential for safe perioperative management of susceptible clients.

Communicate the patient's risk of malignant hyperthermia to the surgical and anesthesia teams

🧯 Clear communication of malignant hyperthermia susceptibility allows the anesthesia team to select nontriggering anesthetic agents.

🧯 Triggering agents such as certain volatile inhaled anesthetics and succinylcholine should be avoided in susceptible individuals.

🧯 Advance notification also ensures that emergency medications, cooling measures, laboratory support, and monitoring are available if needed.

🧯 Interprofessional communication reduces the chance of accidental exposure to a known trigger.

🧯 Therefore, informing the entire perioperative team is a critical preventive nursing action.

Assess and document detailed family history of malignant hyperthermia prior to surgery

🧯 Malignant hyperthermia susceptibility can be inherited, so a detailed family history is an important component of preoperative assessment.

🧯 A history of anesthesia-related unexplained fever, muscle rigidity, cardiac arrest, or known malignant hyperthermia in relatives should be documented clearly.

🧯 Identifying familial risk before surgery allows the anesthesia plan to be modified appropriately.

🧯 Documentation also helps ensure that future healthcare professionals recognize the client's potential susceptibility.

🧯 Therefore, obtaining and recording a detailed family history supports both prevention and long-term patient safety.

Place an allergy or alert band on the patient indicating susceptibility to malignant hyperthermia

🧯 An alert band provides a visible warning that the client is at risk for a potentially life-threatening anesthetic reaction.

🧯 The alert reinforces written documentation and communication among nurses, surgeons, anesthesia personnel, and other perioperative staff.

🧯 It decreases the possibility that triggering medications will be administered inadvertently.

🧯 Such identification is particularly important if the client is sedated, unconscious, or unable to communicate during perioperative care.

🧯 Therefore, placing a clearly visible alert is an appropriate additional safety measure for a susceptible client.

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Answer 10

Correct Answers:

Venous thromboembolism

Rationale :

🩸 Early postoperative ambulation promotes venous circulation in the lower extremities and decreases venous stasis.

🩸 Venous stasis is one component of Virchow's triad and significantly increases the risk for deep vein thrombosis after major orthopedic surgery.

🩸 Hip replacement surgery carries a particularly high risk for deep vein thrombosis and pulmonary embolism because of tissue injury and postoperative immobility.

🩸 Ambulation is commonly combined with anticoagulant prophylaxis, compression devices, and leg exercises as appropriate.

🩸 Therefore, assisting the client to ambulate early is primarily intended to reduce the risk of venous thromboembolism.

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QLexNursing

1 :
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

2 :
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

3 :
A nurse is reviewing the medical history on a client who is preoperative for surgery. Which of the following findings places the client at risk for a postoperative complication?

4 :
A nurse is assessing a postoperative client who received general anesthesia. Which of the following findings should the nurse recognize as manifestations of malignant hyperthermia? (Select all that apply.)

5 :
During a preoperative assessment, a nurse documents that the client has a history of vertigo and orthostatic hypotension. The assessment findings of vertigo and orthostatic hypotension put the client at a high risk for which of the following postoperative complications?

6 :
A client is admitted with septic shock and severe hypovolemia. The healthcare provider orders IV fluid therapy. Which of the following isotonic IV fluids are safe and appropriate for initial resuscitation in this client? (Select all that apply)

7 :
A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (Select all that apply).

8 :
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

9 :
A patient with a known family history of malignant hyperthermia is scheduled for surgery. Which nursing actions are appropriate to prevent and manage a potential malignant hyperthermia crisis? (Select all that apply)

10 :
A nurse is assisting a client with ambulation several hours after a hip replacement. Which of the following postoperative complications is the nurse trying to prevent?

QLexNursing

1 : A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

2 : A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

3 : A nurse is reviewing the medical history on a client who is preoperative for surgery. Which of the following findings places the client at risk for a postoperative complication?

4 : A nurse is assessing a postoperative client who received general anesthesia. Which of the following findings should the nurse recognize as manifestations of malignant hyperthermia? (Select all that apply.)

5 : During a preoperative assessment, a nurse documents that the client has a history of vertigo and orthostatic hypotension. The assessment findings of vertigo and orthostatic hypotension put the client at a high risk for which of the following postoperative complications?

6 : A client is admitted with septic shock and severe hypovolemia. The healthcare provider orders IV fluid therapy. Which of the following isotonic IV fluids are safe and appropriate for initial resuscitation in this client? (Select all that apply)

7 : A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (Select all that apply).

8 : A nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

9 : A patient with a known family history of malignant hyperthermia is scheduled for surgery. Which nursing actions are appropriate to prevent and manage a potential malignant hyperthermia crisis? (Select all that apply)

10 : A nurse is assisting a client with ambulation several hours after a hip replacement. Which of the following postoperative complications is the nurse trying to prevent?

1 :
A nurse is assessing a client who has insomnia. Which of the following questions is the highest priority for the nurse to ask the client?

2 :
A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching?

3 :
A nurse is reviewing the medical history on a client who is preoperative for surgery. Which of the following findings places the client at risk for a postoperative complication?

4 :
A nurse is assessing a postoperative client who received general anesthesia. Which of the following findings should the nurse recognize as manifestations of malignant hyperthermia? (Select all that apply.)

5 :
During a preoperative assessment, a nurse documents that the client has a history of vertigo and orthostatic hypotension. The assessment findings of vertigo and orthostatic hypotension put the client at a high risk for which of the following postoperative complications?

6 :
A client is admitted with septic shock and severe hypovolemia. The healthcare provider orders IV fluid therapy. Which of the following isotonic IV fluids are safe and appropriate for initial resuscitation in this client? (Select all that apply)

7 :
A nurse is assessing a client who has narcolepsy. Which of the following findings should the nurse expect? (Select all that apply).

8 :
A nurse is preparing to administer 0.45% sodium chloride (NaCl) 2000 mL IV to infuse over 8 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

9 :
A patient with a known family history of malignant hyperthermia is scheduled for surgery. Which nursing actions are appropriate to prevent and manage a potential malignant hyperthermia crisis? (Select all that apply)

10 :
A nurse is assisting a client with ambulation several hours after a hip replacement. Which of the following postoperative complications is the nurse trying to prevent?