Nokea
A client had a total abdominal hysterectomy and bilateral oophorectomy for ovarian carcinoma yesterday. She received 2 mg of morphine via PCA 10 minutes ago. The nurse was assisting her from the bed to a chair when the client felt dizzy and fell into the chair. The nurse should:
- A. Discontinue the PCA pump.
- B. Administer oxygen.
- C. Take the client's blood pressure.
- D. Assist the client back to bed.
Correct Answer: C
Rationale: Dizziness after morphine suggests possible hypotension. Taking the blood pressure identifies the cause and guides further action, such as fluid administration or repositioning.
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Which of the following statements would provide the best guide for activity during the rehabilitation period for a client who has been treated for retinal detachment?
- A. Activity is resumed gradually, and the client can resume her usual activities in 5 to 6 weeks.
- B. Activity level is determined by the client's tolerance; she can be as active as she wishes.
- C. Activity level will be restricted for several months, so she should plan on being sedentary.
- D. Activity level can return to normal and may include regular aerobic exercises.
Correct Answer: A
Rationale: Gradual resumption of activity over 5 to 6 weeks allows the retina to heal properly while minimizing the risk of re-detachment or complications.
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
A client is about to undergo bone marrow aspiration of the sternum. Which of the following statements should the nurse include to provide information to the client about what the client will feel during the procedure?
- A. You may feel a warm solution being wiped over your entire front from your neck down to your navel and out to your shoulders.'
- B. You will not feel the local anesthetic being applied because it will be sprayed on.'
- C. You will feel a pulling type of discomfort for a few seconds.'
- D. After the needle is removed, you will feel a bandage being applied around your chest.'
Correct Answer: C
Rationale: During sternal bone marrow aspiration, the client may feel a brief pulling or pressure sensation as the marrow is aspirated. The antiseptic solution is not applied over such a large area, local anesthetic is injected (not sprayed), and a bandage is applied to the site, not around the chest.
Which of the following findings is the best indication that fluid replacement for the client in hypovolemic shock is adequate?
- A. Urine output greater than 30 mL/hour.
- B. Systolic blood pressure greater than 110 mm Hg.
- C. Diastolic blood pressure greater than 90 mm Hg.
- D. Respiratory rate of 20 breaths/minute.
Correct Answer: A
Rationale: Adequate fluid replacement in hypovolemic shock is best indicated by a urine output greater than 30 mL/hour, reflecting restored renal perfusion. Blood pressure and respiratory rate improvements are supportive but less specific.
The primary goal for the client with Buerger's disease is to prevent:
- A. Embolus formation
- B. Fat embolus formation
- C. Thrombophlebitis
- D. Gangrene
Correct Answer: D
Rationale: The primary goal in Buerger's disease is to prevent gangrene, as the condition causes severe arterial and venous inflammation, leading to occlusion and tissue ischemia. Smoking cessation and vasodilation are key to avoiding tissue necrosis. Embolus, fat embolus, or thrombophlebitis are less specific concerns.