Nokea
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. constipation.
- C. sedation.
- D. addiction.
Correct Answer: D
Rationale: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.
You may also like to solve these questions
Which of the following statements to the client's family would be appropriate when preparing to provide postmortem care to the client?
- A. You will not be allowed to see your family member after the post-mortem care is performed.
- B. I am not able to assist you, but we can call pastoral care if you need any comfort.
- C. Unfortunately, we are not allowed to incorporate any cultural practices in my preparations.
- D. I will be ensuring that your family member is properly identified before they are transported.
Correct Answer: D
Rationale: When providing post-mortem care, ensure the patient is properly identified and labeled before transporting. If possible, cultural practices should be incorporated, and the family should be allowed to see the client. When possible, the nurse should provide comfort to the family.
The hospitalized client is at risk for thromboembolism. Which direction should the nurse include when teaching this client about wearing antiembolism hose stockings?
- A. Wearing the hose is unnecessary if ambulating 10 times daily for 5 minutes at a time.
- B. When at home, apply the stockings in the morning before you stand to get out of bed.
- C. The hose can cause pain to underlying skin; request pain medication to help alleviate this.
- D. Cross your legs only while wearing these stockings; otherwise keep the legs uncrossed.
Correct Answer: B
Rationale: B: Applying stockings before standing maximizes compression and prevents edema. A: Stockings complement ambulation. C: Pain suggests circulation issues, not requiring pain medication. D: Crossing legs impedes circulation.
An LPN is caring for a primarily bedridden client. Which finding should be of least concern?
- A. swollen feet
- B. brown discoloration above the ankles
- C. leg pain
- D. capillary refill time of 3 seconds on the big toe
Correct Answer: D
Rationale: Capillary refill time of longer than three seconds may indicate inadequate blood flow; capillary refill time of 2-3 seconds is a normal finding. Swollen feet, brown discoloration, and leg pain may be signs of venous insufficiency to the lower extremities.
Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency? A .Shear-reducing mattress B. Sequential compression devices C. Compression stockings D.Non-skid socks
- A. B and C
- B. A and D
- C. B and D
- D. A and C
Correct Answer: A
Rationale: For a client with venous insufficiency, sequential compression devices (SCDs) and compression stockings can be applied to improve venous return from the lower extremities.
A hospitalized adult client who routinely works from midnight until 8 a.m. has a temperature of 99.1°F at 4 a.m. The nurse determines that this is most likely due to:
- A. delta sleep
- B. slow brain waves
- C. pneumonia
- D. circadian rhythm
Correct Answer: D
Rationale: Biological rhythms that follow a cycle lasting about 24 hours are termed circadian rhythm. The sleep-wake cycle is closely linked with cardiac rhythms, such as body temperature. While a person sleeps, core body temperature drops, often reaching the 24-hour low at 4 a.m. When the sleep period shifts, temperature fluctuations also shift to match the new sleep patterns.