Nokea
A 68-year-old client with colon cancer experiences an increase in his feelings of anxiety and depression and has suicidal ideation. He appears to be in great distress. The nurse realizes that he is at which stage in his disease?
- A. Initiation of definitive treatment.
- B. End of his first course of treatment.
- C. End stage of his disease.
- D. Recurrence of the disease.
Correct Answer: C
Rationale: Increased anxiety, depression, and suicidal ideation suggest the client is in the end stage of colon cancer, facing mortality and existential distress.
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A client returned from surgery with a debrided open tibial fracture and has a three-way drainage system. The nurse should first:
- A. Review the results of culture and sensitivity testing of the wound.
- B. Look for the presence of a pressure dressing over the wound.
- C. Determine if the client has increased pain from exposed nerve endings.
- D. Check the client's blood pressure for hypotension resulting from additional vessel bleeding.
Correct Answer: D
Rationale: Checking blood pressure for hypotension is the priority, as bleeding from an open fracture can be life-threatening.
A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client?
- A. Observing the client at regular intervals for opioid addiction.
- B. Encouraging the client to reduce analgesic use and tolerate the pain.
- C. Evaluating pain control at least every 2 hours.
- D. Increasing the amount of morphine if the client does not administer the medication.
Correct Answer: C
Rationale: Regularly evaluating pain control ensures adequate relief while monitoring for side effects, a priority in PCA management.
A nurse is instructing a client who had abdominal surgery that day to do deep-breathing exercises. In which order should the nurse teach the client to perform diaphragmatic breathing and coughing?
- A. Inhale through the nose.
- B. Cough deeply from the lungs.
- C. Exhale through pursed lips.
- D. Splint the incisional site.
Correct Answer: D,A,C,B
Rationale: The correct order is: splint the incision (D) to reduce pain, inhale through the nose (A) to expand lungs, exhale through pursed lips (C) to control breathing, and cough deeply (B) to clear secretions.
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
The nurse is preparing a continuing education course on blood transfusion reactions. The nurse recognizes which intervention would prevent an ABO incompatibility (hemolytic) transfusion error.
- A. Priming a Y-tubing blood administration set with 0.9% sodium chloride (normal saline).
- B. Ensure that the client has a patent 20-gauge peripheral vascular access device.
- C. Accurately label the client's blood specimen for crossmatching.
- D. Review the client's medication allergies.
Correct Answer: C
Rationale: Accurate labeling of the client’s blood specimen for crossmatching ensures the correct blood type is matched, preventing ABO incompatibility reactions. Priming with saline, ensuring IV access, and reviewing allergies do not directly prevent ABO mismatches.