Nokea
A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct Answer: A
Rationale: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.
You may also like to solve these questions
The client asks the nurse, 'Why can't the doctor tell me exactly how much of my leg they're going to take off? Don't you think I should know that?' The nurse responds, knowing that the final decision on the level of the amputation will depend primarily on:
- A. The need to remove as much of the leg as possible
- B. The adequacy of the blood supply to the tissues
- C. The ease with which a prosthesis can be fitted
- D. The client's ability to walk with a prosthesis
Correct Answer: B
Rationale: The level of amputation depends primarily on the adequacy of blood supply to the tissues, as determined intraoperatively. Sufficient perfusion is necessary for healing and preventing further necrosis. Removing excess tissue, prosthesis fitting, or walking ability are secondary considerations.
The expected outcome of using miotics to treat glaucoma is:
- A. Paralyzing ciliary muscles.
- B. Constricting intraocular vessels.
- C. Constricting the pupil.
- D. Relaxing ciliary muscles.
Correct Answer: C
Rationale: Miotics (e.g., pilocarpine) constrict the pupil, which opens the drainage angle of the eye, facilitating aqueous humor outflow and reducing intraocular pressure.
The physician prescribes sulfasalazine (Azulfidine) for the client with ulcerative colitis to continue taking at home. Which instruction should the nurse give the client about taking this medication?
- A. Avoid taking it with food.
- B. Take the total dose at bedtime.
- C. Take it with a full glass (240 mL) of water.
- D. Stop taking it if urine turns orange-yellow.
Correct Answer: C
Rationale: Sulfasalazine should be taken with a full glass of water to ensure proper absorption and to prevent gastrointestinal irritation. It can be taken with food to reduce stomach upset, the dose is typically spread out during the day, and orange-yellow urine is a harmless side effect. CN: Pharmacological and parenteral therapies; CL: Synthesize
A new medication regimen is ordered for a client with Parkinson's disease. At which time should the nurse make certain that the medication is taken?
- A. At bedtime.
- B. All at one time.
- C. Two hours before mealtime.
- D. At the time scheduled.
Correct Answer: D
Rationale: Adhering to the scheduled times ensures consistent drug levels, critical for managing Parkinson's symptoms. Bedtime, single dosing, or pre-meal timing may disrupt therapeutic efficacy.
A client with Addison's disease is admitted to the medical unit. The nurse diagnoses the client with Deficient fluid volume related to inadequate fluid intake and to fluid loss secondary to inadequate adrenal hormone secretion. As the client's oral intake increases, which of the following fluids would be most appropriate?
- A. Milk and diet soda.
- B. Water and eggnog.
- C. Bouillon and juice.
- D. Coffee and milkshakes.
Correct Answer: C
Rationale: Bouillon provides sodium, and juice offers hydration and calories, supporting fluid and electrolyte balance in Addison's disease.