Nokea
A 52-year-old female had a hysterectomy 3 days ago and is recovering on the post-op floor. She is scheduled for an oral pain medication every 4 hours. She received her scheduled dose 1 hour ago but pushes the call light and complains of unrelenting and severe pain. The nurse should first
- A. perform a full head-to-toe assessment on the client.
- B. work with the client on alternate methods to relieve pain, such as guided imagery.
- C. explain to the client it is not time to administer more pain medication.
- D. call the physician and report the current plan for pain management is not working.
Correct Answer: D
Rationale: Severe, unrelenting pain post-hysterectomy suggests a complication (e.g., bleeding, infection). Notifying the physician for evaluation is the priority.
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A client with $B$ positive blood is scheduled for a transfusion of whole blood. Which finding requires nursing intervention?
- A. The available blood has been banked for 2 weeks.
- B. The blood available for transfusion is Rh negative.
- C. The client has a peripheral IV of D5 $1 / 2$ normal saline.
- D. The blood available for transfusion is type 0 positive.
Correct Answer: B
Rationale: Transfusing Rh-negative blood to an Rh-positive client can cause incompatibility reactions, requiring intervention to ensure Rh compatibility.
The nurse is supervising a student nurse on the oncology unit who is providing care for a client with neutropenic precautions. Which action by the student nurse requires intervention by the supervising nurse?
- A. Vital signs, including temperature, are monitored every 4 hours.
- B. The student nurse inspects the client's mouth at least every 8 hours.
- C. The student nurse delivers a potted plant to the room sent by the client's family.
- D. The student nurse washes her hands before performing client care or touching client belongings.
Correct Answer: C
Rationale: Potted plants pose an infection risk (e.g., mold) for neutropenic clients and are prohibited. Other actions are appropriate.
Two Mexican immigrant families live closely together and share goods, services, and childcare. To which of the following family structures does this model correspond?
- A. Kinship network
- B. Binuclear
- C. Nuclear
- D. Extended
Correct Answer: A
Rationale: A kinship network (A) involves close family units sharing resources, typical in some Mexican cultures. Extended (D) is broader, nuclear (C) is single-family, and binuclear (B) involves divorce.
The nurse is performing discharge diet teaching to a client with a stage 1 decubitus ulcer on the coccyx. Which diet selection by this client would indicate that the client has a clear understanding of the proper diet for healing of a decubitus ulcer?
- A. Tossed salad, milk, and a slice of caramel cake
- B. Vegetable soup and crackers, and a glass of tea
- C. Baked chicken breast, broccoli, wheat roll, and an orange
- D. Hamburger, French fries, and corn on the cob
Correct Answer: C
Rationale: Healing a decubitus ulcer requires a diet high in protein, vitamins (especially C and A), and minerals like zinc. Baked chicken (protein), broccoli (vitamin A), wheat roll (carbohydrates), and orange (vitamin C) support tissue repair. The other options lack sufficient protein or include high-sugar/fat items that don't aid healing.
A client with AIDS is taking Zovirax (acyclovir). Which nursing intervention is most critical during the administration of acyclovir?
- A. Limit the client's activity
- B. Encourage a high-carbohydrate diet
- C. Utilize an incentive spirometer to improve respiratory function
- D. Encourage fluids
Correct Answer: D
Rationale: Acyclovir can cause nephrotoxicity, so encouraging fluids is critical to prevent kidney damage.