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A client has an epidural catheter inserted for postoperative pain management. The client rates his pain at 4 on a 0-to-5 pain scale. What should the nurse do first?
- A. Check the patient-controlled analgesia (PCA) pump function.
- B. Adjust the epidural catheter.
- C. Assess vital signs.
- D. Notify the physician.
Correct Answer: C
Rationale: Assessing vital signs first ensures the client is stable, as a pain level of 4 may indicate complications (e.g., respiratory depression). Checking the pump, adjusting the catheter, or notifying the physician follow if needed.
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The client has midcalf pain when walking a block or more. The client states that the discomfort is relieved with rest. The pain is expected when arterial occlusion reaches which of the following percentages?
- A. 20%
- B. 40%
- C. 50%
- D. 100%
Correct Answer: C
Rationale: Claudication typically occurs when arterial occlusion reaches approximately 50%, significantly reducing blood flow to muscles during activity. This causes ischemia and pain, which is relieved by rest when oxygen demand decreases. Complete (100%) occlusion would cause rest pain or tissue necrosis, not just claudication.
The nurse's best explanation for why the severely neutropenic client is placed in reverse isolation is that reverse isolation helps prevent the spread of organisms:
- A. To the client from sources outside the client's environment.
- B. From the client to health care personnel, visitors, and other clients.
- C. By using special techniques to dispose of contaminated materials.
- D. By using special techniques to handle the client's linens and personal items.
Correct Answer: A
Rationale: Reverse isolation protects severely neutropenic clients by preventing the introduction of pathogens from external sources, such as staff, visitors, or equipment. It is not about preventing spread from the client or specific disposal/handling techniques.
A 48-year-old client with cancer has been receiving 10 mg of I.V. morphine while hospitalized. In control, the nurse should administer which of the following doses of oral morphine?
- A. 25 mg.
- B. 30 mg.
- C. 40 mg.
- D. 10 mg.
Correct Answer: B
Rationale: The equianalgesic conversion from 10 mg I.V. morphine to oral morphine (1:3 ratio) is 30 mg, as oral morphine has lower bioavailability due to first-pass metabolism.
The client is scheduled to have a kidney, ureter, and bladder (KUB) radiograph. To prepare the client for this procedure, the nurse should explain to the client that:
- A. Fluid and food will be withheld the morning of the examination.
- B. A tranquilizer will be given before the examination.
- C. An enema will be given before the examination.
- D. No special preparation is required for the examination.
Correct Answer: D
Rationale: A KUB radiograph requires no special preparation, as it is a non-invasive imaging test to locate renal calculi.
Which symptom indicates a potential complication in a client post-craniotomy?
- A. Mild headache.
- B. Clear nasal drainage.
- C. Stable blood pressure.
- D. Improved appetite.
Correct Answer: B
Rationale: Clear nasal drainage may indicate cerebrospinal fluid leakage, a serious post-craniotomy complication.