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A 13 year old girl is admitted to the ER with lower right abdominal discomfort. The admitting nursing should take which the following measures first?
- A. Administer Loritab to the patient for pain relief.
- B. Place the patient in right sidelying position for pressure relief.
- C. Start a Central Line.
- D. Provide pain reduction techniques without administering medication.
Correct Answer: D
Rationale: Do not administer pain medication or start a central line without MD orders.
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A client is admitted with a diagnosis of myxedema. An initial assessment of the client would reveal the symptoms of:
- A. Slow pulse, weight loss, diarrhea, and cardiac failure
- B. Weight gain, lethargy, slowed speech, and decreased respiratory rate
- C. Rapid pulse, constipation, and bulging eyes
- D. Decreased body temperature, weight loss, and increased respiratory rate
Correct Answer: B
Rationale: Myxedema (severe hypothyroidism) causes weight gain, lethargy, slowed speech, and decreased respiratory rate due to slowed metabolism. Other options describe hyperthyroidism or mixed symptoms.
A patient with effective pain relief.
Which of the following nursing actions is MOST important to provide a patient with effective pain relief?
- A. Teach the patient about his pain.
- B. Establish a trusting relationship with the patient.
- C. Determine how various relaxation techniques affect the pain.
- D. Provide alternative measures to relieve pain.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) not most important (2) correct-necessary to work with patient to identify interventions to relieve pain (3) part of intervention and evaluation phase (4) only a portion of interventions used to relieve pain
The nurse is caring for a client who is post-op following a thoracotomy. The client has 2 chest tubes in place, connected to 1 chest drain. The nursing assessment reveals bubbling in the water seal chamber when the client coughs. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Continue to monitor the client to see if the bubbling increases
- D. Instruct the client to try to avoid coughing
Correct Answer: C
Rationale: Bubbling associated with coughing after lung surgery is to be expected as small amounts of air escape the pleural space when pressures inside the chest increase with coughing. Monitoring is the only nursing action required at this time.
The nurse observes the student nurse enter wearing a gown, gloves, and a mask.
The nurse determines that the precautions are correct if the student nurse is caring for which of the following clients?
- A. An infant diagnosed with respiratory syncytial virus.
- B. A young child with a wound infected with S aureus.
- C. A teenager diagnosed with toxic shock syndrome.
- D. A teenager diagnosed with rubella (German measles).
Correct Answer: D
Rationale: Strategy: Determine the precautions required for each disease. (1) requires contact precautions, no mask (2) requires contact precautions, no mask (3) standard precautions (4) correct-droplet precautions used for organisms that can be transmitted by face-to-face contact, door may remain open
The nurse asks a client with a history of alcoholism about recent drinking behavior. The client states 'I didn't hurt anyone. I just like to have a good time, and drinking helps me to relax.' The client is using which defense mechanism?
- A. Denial
- B. Projection
- C. Intellectualization
- D. Rationalization
Correct Answer: D
Rationale: Rationalization. The client justifies drinking by providing acceptable explanations for unacceptable behavior.