Nokea
Which of these clients who are all in the terminal stage of cancer is least appropriate to suggest the use of patient controlled analgesia (PCA) with a pump?
- A. A young adult with a history of Down syndrome
- B. A teenager who reads at a 4th grade level
- C. An elderly client with numerous arthritic nodules on the hands
- D. A preschooler with intermittent episodes of alertness
Correct Answer: D
Rationale: A preschooler with intermittent episodes of alertness. A preschooler is most likely of these clients to have difficulty with the use or understanding of a PCA pump. This very young child lacking a normal level of consciousness would not benefit from the use of a PCA pump.
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The charge nurse is planning hospital bed placements for the five male clients identified in the exhibit. Two double rooms and one private room are available. Which room assignments should be made by the charge nurse?
- A. Client B: private room; clients C and E in same room; clients A and D in same room
- B. Client C: private room; clients A and D in same room; clients B and E in same room
- C. Client E: private room; clients B and C in same room; clients A and D in same room
- D. Client C: private room; clients A and B in same room; clients D and E in same room
Correct Answer: B
Rationale: B: Client C requires airborne precautions and a private room. A and D share the same organism and contact precautions. B and E require standard precautions and can share a room.
Constipation is one of the most frequent complaints of elders. When assessing this problem, which action should be the nurse's priority?
- A. obtain a complete blood count
- B. obtain a health and dietary history
- C. refer to a provider for a physical examination
- D. measure height and weight
Correct Answer: B
Rationale: obtain a health and dietary history. Initially, the nurse should obtain information about the chronicity of and details about constipation, recent changes in bowel habits, physical and emotional health, medications, activity pattern, and food and fluid history. This information may suggest causes as well as an appropriate, safe treatment plan.
The nurse is caring for a client undergoing the placement of a central venous catheter line. Which of the following would require the nurse's immediate attention?
- A. Pallor
- B. Increased temperature
- C. Dyspnea
- D. Involuntary muscle spasms
Correct Answer: C
Rationale: Dyspnea. Clients having the insertion of a central venous catheter are at risk for tension pneumothorax. Dyspnea, shortness of breath and chest pain are indications of this complication.
A client is being discharged with a prescription for chlorpromazine (Thorazine). Before leaving for home, which of these findings should the nurse teach the client to report?
- A. Change in libido, breast enlargement
- B. Sore throat, fever
- C. Abdominal pain, nausea, diarrhea
- D. Dyspnea, nasal congestion
Correct Answer: B
Rationale: A sore throat and fever may be findings of agranulocytosis, a serious side effect of chlorpromazine (Thorazine).
The nurse educator is focusing on the prevention of infection. Place an X on the illustration that displays the best measure to prevent infection when caring for clients on a nursing unit?
- A. infection_1.PNG
- B. infection_2.PNG
- C. infection_3.PNG
- D. infection_4.PNG
- E. infection_5.PNG
Correct Answer: A
Rationale: A: Hand hygiene is the most effective measure to prevent infection transmission. Other measures like isolation or gloves are situational, but hand washing is universally critical.