Nokea
A client has a tibial fracture that required casting. Approximately 5 hours later, the client has increasing pain distal to the left tibial fracture despite the morphine injection administered 30 minutes previously. Which of the following should be the nurse's next assessment?
- A. Presence of a distal pulse.
- B. Pain with a pain rating scale.
- C. Skin temperature.
- D. Potential for drug tolerance.
Correct Answer: A
Rationale: Increasing pain despite analgesia suggests compartment syndrome; checking the distal pulse assesses for vascular compromise.
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The nurse is planning a staff development conference about medication safety. Which of the following medications should have a second medication check prior to administration? Select all that apply.
- A. heparin infusion
- B. regular insulin
- C. 0.9% sodium chloride (normal saline) flush
- D. patient-controlled analgesia (PCA)
- E. oxytocin infusion
- F. total parenteral nutrition
Correct Answer: A,B,D,E,F
Rationale: High-risk medications like heparin, insulin, PCA, oxytocin, and TPN require a second check to prevent errors.
A 56-year-old female is currently receiving radiation therapy to the chest wall for recurrent breast cancer. She has pain while swallowing and burning and tightness in her chest. The nurse should further assess the client for indications of:
- A. Hiatal hernia.
- B. Stomatitis.
- C. Radiation enteritis.
- D. Esophagitis.
Correct Answer: D
Rationale: Pain while swallowing and chest burning/tightness suggest esophagitis, a common side effect of chest wall radiation due to irritation of the esophageal mucosa.
Which assessment finding is expected in the oliguric phase of acute renal failure?
- A. Weight gain.
- B. Hypotension.
- C. Clear urine.
- D. Low BUN levels.
Correct Answer: A
Rationale: Weight gain occurs due to fluid retention in the oliguric phase.
If the client realizes the importance of quitting smoking, and the nurse develops a plan to help the client achieve this goal. Which of the following nursing interventions should be the initial step in this plan?
- A. Review the negative effects of smoking on the body.
- B. Discuss the effects of passive smoking on environmental pollution.
- C. Establish the client's daily smoking pattern.
- D. Explain how smoking worsens high blood pressure.
Correct Answer: C
Rationale: Establishing the daily smoking pattern identifies triggers and habits, forming the basis for a tailored cessation plan.
A client with a suspected diagnosis of Hodgkin's disease is to have a lymph node biopsy. Which action is correct for handling the lymph node biopsy specimen for histologic examination for this client?
- A. Maintain sterile technique.
- B. Use a mask, gloves, and a gown when assisting with the procedure.
- C. Place the specimen in a container and send it to the laboratory when someone is available to take it.
- D. Call for a laboratory technician to assist the physician.
Correct Answer: C
Rationale: The lymph node biopsy specimen should be placed in a container and sent to the laboratory promptly to preserve tissue integrity for histologic examination. Sterile technique is maintained during the procedure, not for handling afterward, and masks/gowns or technician assistance are not required for transport.