Nokea
A client had a right below-the-knee amputation 4 days ago. He is complaining of pain in his right lower leg. The nurse should:
- A. Remind the client that he no longer has that part of his leg and assure him he will be OK
- B. Call the physician to request a psychological consultation for the client
- C. Turn on the television to distract the client's attention from his amputated leg
- D. Give the client his order of Demerol 50 mg IM prn
Correct Answer: D
Rationale: Phantom pain is a normal, very real experience for an amputee and should be treated with pain medication.
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A pregnant client experiences spontaneous rupture of membranes. The first nursing action is to:
- A. Assess the client's respirations
- B. Notify the physician
- C. Auscultate fetal heart rate
- D. Transfer to delivery suite
Correct Answer: C
Rationale: Auscultating fetal heart rate is critical after membrane rupture to assess for cord prolapse, a potential complication.
A chronic alcoholic client's condition deteriorates, and he begins to exhibit signs of hepatic coma. Which of the following is an early sign of impending hepatic coma?
- A. Hiccups
- B. Anorexia
- C. Mental confusion
- D. Fetor hepaticus
Correct Answer: C
Rationale: One of the earliest symptoms of hepatic coma is mental confusion. Asterixis, a flapping tremor of the hand, may also be seen.
When caring for a postoperative cholecystectomy client, the nurse assesses patency and documents drainage of the T-tube. The nurse recognizes that the expected amount of drainage during the first 24 hours postoperatively is:
- A. 50-100 mL
- B. 200-300 mL
- C. 300-500 mL
- D. 1000-1200 mL
Correct Answer: C
Rationale: During the first 24 hours after surgery, the drainage is normally 300-500 mL and then decreases to about 200 mL in 24 hours during the next 3-4 days. This range is the amount of drainage after the first 24 hours postoperatively. During the first 24 hours, it is 300-500 mL. During the first 24 hours after surgery, this range is the expected amount of drainage. The expected amount of drainage during the first 24 hours is 300-500 mL. An output of >500 mL should be reported to the physician, because an occlusion of some type, caused by a retained gallstone or an inflammatory process within the biliary drainage system, is evident.
The nurse has just received the change of shift report and is preparing to make rounds. Which client should the nurse assess first?
- A. A client recovering from a stroke with an oxygen saturation rate of 99%
- B. A client three days post-coronary artery bypass graft with an oral temperature of 100.2°F
- C. A client admitted one hour ago with rales and shortness of breath
- D. A client being prepared for discharge following a right colectomy
Correct Answer: C
Rationale: The client admitted one hour ago with rales and shortness of breath indicates potential acute respiratory distress, possibly from pulmonary edema or pneumonia, requiring immediate assessment. The other clients are stable or less urgent.
Diphenoxylate hydrochloride and atropine sulfate (Lomotil) is prescribed for the client with ulcerative colitis. Which of the following nursing observations indicates that the drug is having a therapeutic effect?
- A. There is an absence of peristalsis.
- B. The number of diarrhea stools decreases.
- C. Cramping in the abdomen has increased.
- D. Abdominal girth size increases.
Correct Answer: B
Rationale: Lomotil, an antidiarrheal, slows intestinal motility, reducing diarrhea frequency in ulcerative colitis. Decreased diarrhea stools (B) indicates therapeutic effect. Absent peristalsis (A), increased cramping (C), or girth (D) suggest complications or ineffectiveness.