The nurse is caring for a client who just returned from the recovery room after a tonsillectomy and adenoidectomy. The client is restless, and the pulse rate is increased. The nurse continues to assess the client, but the client begins to vomit large amounts of bright red blood.

What is the immediate nursing action?

Read the question carefully, noting the strategic word immediate. Several other noteworthy words in this question include restless, pulse rate is increased, large amounts, and bright red blood. The subject of the question is that the client is actively bleeding and is exhibiting signs of shock (restlessness and increased pulse rate), indicating a life-threatening situation. Remember to always read each option carefully. In this situation and from the options provided, the nurse would contact the health care provider, and in this question, it is the surgeon. Options 2, 3, and 4 would delay necessary interventions needed in this life-threatening situation.

Whenever you note that a client is bleeding and the amount is large and bright red, you would become concerned because this indicates active bleeding. Active bleeding is a concern after any type of surgery, including a tonsillectomy and adenoidectomy, and indicates a potential life-threatening situation. You will learn about postoperative complications in your fundamentals of nursing course, and you will learn specifically about tonsillectomy and adenoidectomy in your pediatrics nursing course. Be sure to learn the postoperative complications and the immediate nursing interventions.

The nurse enters a client’s room and finds the client slumped over in bed. The nurse quickly assesses the client and discovers that the client is not breathing and there is no pulse.

The nurse should take which immediate action?

Read the question carefully, note the strategic word immediate, and focus on the subject—the client is not breathing and there is no pulse. Although the information in the question indicates a life-threatening situation, you need to read all options carefully. In this situation and based on the options provided, the nurse needs to intervene immediately. Although the health care provider needs to be called, the immediate nursing action would be to begin CPR. Options 1 and 4 are incorrect, because neither of these options will assist this client.

It is important to read all the information in the question and focus on every word. Note that the client is not breathing and there is no pulse. Therefore you need to begin CPR. You were most likely required to obtain health care certification in basic life support and CPR before entering nursing school. Be sure to review these procedures, especially because you will be caring for clients during your clinical experiences in your nursing program.

A nurse is caring for a postoperative client who suddenly becomes restless.

The nurse should take which most appropriate action?

Read the question carefully, note the strategic words most appropriate, and focus on the subject—a postoperative client who becomes restless. No data in the question indicate that the client has pain; therefore, eliminate option 1. Because option 4 is a psychosocial action rather than a physiological one (physiological needs are the priority), eliminate that option using Maslow’s Hierarchy of Needs theory. Recall that restlessness can be an early sign of shock. However, no data in the question indicate a life-threatening condition. Therefore, the nurse would gather more data about the client’s condition and should most appropriately check the client’s vital signs.

One complication following surgery is the development of shock, which is usually due to bleeding or an excessive loss of blood during the surgical procedure. The nurse always monitors the postoperative client for signs of shock. One of the earliest signs of shock is restlessness. If restlessness is noted, the nurse would check the client’s vital signs next. In shock, the nurse would note that the blood pressure decreases and the pulse rate increases. You will learn about shock as a postoperative complication in your fundamentals of nursing course. Be sure to focus on the signs of shock and the immediate nursing interventions.

The nurse is caring for a hospitalized client with angina pectoris who begins to experience chest pain. The nurse administers a sublingual nitroglycerin (Nitrostat) tablet as prescribed, but the pain is unrelieved. The nurse checks the client’s blood pressure and notes that it is stable.

Which action should the nurse take next?

Note the strategic word next, and focus on the subject—the client is experiencing chest pain. Recalling that for a hospitalized client the nurse would administer 3 nitroglycerin tablets 5 minutes apart from each other to relieve chest pain will assist in directing you to option 4. Repositioning the client will not alleviate pain associated with angina pectoris. The nurse would call the health care provider if 3 nitroglycerin tablets administered 5 minutes apart from each other did not alleviate the pain. There is no useful reason to call the client’s family at this time.

Angina pectoris refers to chest pain that is most often caused by a lack of oxygen to myocardial tissue and occurs as a result of atherosclerosis (clogged blood vessels) or spasm of the coronary arteries. The pain may be relieved by rest and vasodilation of the coronary arteries by medication, such as nitroglycerin. The usual protocol for administering nitroglycerin to a hospitalized client is to administer a total of 3 tablets, 5 minutes apart each, to relieve the chest pain. In other words, a nitroglycerin tablet is administered, and if the pain is not relieved in 5 minutes, another is administered. This is repeated in 5 minutes, 1 more time, if the pain is not relieved by the second nitroglycerin tablet. After administering 3 nitroglycerin tablets, if the pain is still unrelieved, the health care provider is called. It is also important for the nurse to monitor the client’s blood pressure because nitroglycerin causes a drop in the blood pressure. You will learn about angina pectoris and nitroglycerin during your medical-surgical nursing course. Because this is a major, life-threatening disorder, it is critical that you learn about its signs and symptoms and immediate treatment.

An infant with tetralogy of Fallot experiences a hypercyanotic spell during a blood draw.

The nurse should take which action first?

Note the strategic word first, and focus on the subject of the question—a hypercyanotic spell. In questions that require you to determine the first nursing action, if 1 of the options indicates client positioning, that option may be the correct one. Positioning a client can relieve a symptom and is an intervention that takes only seconds to implement. Placing the infant in the knee-chest position reduces the venous return from the legs (which is desaturated) and increases systemic vascular resistance, which diverts more blood flow into the pulmonary artery. Note that the remaining options all require a health care provider’s prescription. Your next action would be to administer oxygen to the infant. Remembering that morphine sulfate reduces spasm that occurs with these spells and that IV fluids are not always needed to treat these spells will assist in determining the order of priority for the remaining 2 interventions.

Tetralogy of Fallot is a congenital cardiac anomaly that consists of 4 defects in the heart: pulmonary stenosis, ventricular septal defect, malposition of the aorta so that it arises from the septal defect or the right ventricle, and right ventricular hypertrophy. The treatment consists primarily of supportive measures and palliative surgical procedures until the child is old enough to tolerate total corrective surgery. It would be helpful to review the anatomy and physiology of the heart. In addition, you will learn about tetralogy of Fallot when you take your pediatrics nursing course.