Nokea
A client has been diagnosed with vasospastic disorder (Raynaud's phenomenon) on the tip of the nose and fingertips. The physician has prescribed reserpine (Serpasil) to determine if the client will obtain relief. The client's history reveals that he lives in Vermont and works outside in the logging industry. He smokes two packs of cigarettes a day. Which of the following components are an important part of the discharge plan for this client? Select all that apply.
- A. Stopping smoking
- B. Wearing a face covering and gloves in the winter
- C. Placing fingertips in cool water to rewarm them
- D. Finding employment that can be done in a warm environment
- E. Reporting signs of orthostatic hypotension
Correct Answer: A,B,D,E
Rationale: Rationales: A) Stopping smoking reduces vasoconstriction triggered by nicotine, critical in Raynaud's. B) Face covering and gloves protect against cold, a trigger for vasospasm. D) Working in a warm environment minimizes cold exposure. E) Reserpine may cause orthostatic hypotension, requiring monitoring. C) Cool water worsens vasospasm; warm water is recommended.
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A client returned to the recovery room after a dilatation and curettage has the postoperative medication orders shown in the chart. What should the nurse do next?
- A. Ask the client to rate the intensity of her painon a scale of 1 to 10 and administer the analgesia according to the intensity of the pain.
- B. Administer the Demerol fi rst because the client had surgery today.
- C. Administer the Tylenol #3 fi rst, and if it does not relieve the pain in 2 hours, administer the Demerol.
- D. Administer the Motrin fi rst and if it does not relieve the pain, administer the Demerol.
Correct Answer: A
Rationale: The nurse must fi rst assess the intensity of the client’s pain before selecting the correct analgesia. A high score would necessitate administering the meperidine (Demerol). If the intensity rating is low, an oral analgesic would be appropriate. If acetaminophen (Tylenol #3) is given without assessing the intensity of the client’s pain, the nurse must then wait 4 hours before administering another analgesic
Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled?
- A. Muscle spasms.
- B. Nausea.
- C. Shivering.
- D. Dry mouth.
Correct Answer: B
Rationale: Ondansetron is an antiemetic, effective when nausea is controlled.
As a first step in teaching a woman with a spinal cord injury and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which of the following statements by the client indicates she understands her current ability?
- A. I will be able to have sexual intercourse until the urinary catheter is removed.'
- B. I can participate in sexual activity but might not experience orgasm.'
- C. I can't have sexual intercourse because it causes hypertension, but other sexual activity is okay.'
- D. I should be able to participate in sexual activity, but I will be infertile.'
Correct Answer: B
Rationale: Quadriplegia may impair sensation and orgasm but does not preclude sexual activity, which the client correctly understands.
The nurse is reviewing acetaminophen (APAP) toxicity with students. The nurse should remind students that the maximum acetaminophen dosage for an adult is
- A. 2,000 mg per day
- B. 4,000 mg per day
- C. 5,000 mg per day
- D. 6,000 mg per day
Correct Answer: B
Rationale: The maximum recommended adult dose of acetaminophen is 4,000 mg per day to avoid liver toxicity.
When teaching the client to care for an ileal conduit, the nurse instructs the client to empty the appliance frequently. Which of the following indicate that the client is following instructions?
- A. The skin around the stoma is red.
- B. The urine is a deep yellow.
- C. There is no odor present.
- D. The seal around the stoma is intact.
Correct Answer: C,D
Rationale: No odor and an intact seal indicate frequent emptying, preventing urine leakage and skin irritation. Red skin or deep yellow urine suggest inadequate care or dehydration.