Nokea
A client is admitted to the emergency department with a full thickness burn to his right arm. Upon assessment, the arm is edema, the agent is mottled, and radial pulse is now absent. The client states that the pain is 8 on a scale of 1 to 10 . The nurse should:
- A. Administer morphine sulfate I.V. push for the severe pain.
- B. Call the physician to report the loss of the radial pulse.
- C. Continue to assess the arm every hour for any additional changes.
- D. Instruct the client to exercise his fingers and wrist.
Correct Answer: B
Rationale: The absence of the radial pulse indicates potential compartment syndrome or vascular compromise, which is a medical emergency requiring immediate physician notification to prevent tissue necrosis.
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A client with bladder cancer has lost an estimated 500 mL blood in the urine. The client's hemoglobin is 8.0 g/dL, and the physician orders a unit of packed blood cells. To administer the packed red blood cells, the nurse should:
- A. Attach the packed cells to the existing 19G I.V. of normal saline solution using Y tubing.
- B. Start an additional 22G I.V. site because the packed blood cells must be given in a separate line.
- C. Attach the packed blood cells to the existing 22G I.V. of 5% dextrose using Y tubing.
- D. Start an additional I.V. access device with a 22G Intracath.
Correct Answer: A
Rationale: Packed red blood cells should be administered via a 19G I.V. with normal saline using Y tubing to prevent hemolysis, which can occur with dextrose solutions.
What is a priority nursing intervention for a client with renal colic?
- A. Encourage fluid intake.
- B. Administer morphine as prescribed.
- C. Apply warm compresses.
- D. Insert a urinary catheter.
Correct Answer: B
Rationale: Morphine effectively manages severe renal colic pain, prioritizing client comfort.
Clients who have had active tuberculosis are at risk for recurrence. Which of the following conditions increases that risk?
- A. Cool and damp weather.
- B. Active exercise and exertion.
- C. Physical and emotional stress.
- D. Rest and inactivity.
Correct Answer: C
Rationale: Physical and emotional stress can weaken the immune system, increasing the risk of tuberculosis recurrence. Weather, exercise, and rest do not directly influence recurrence.
The client with type 1 diabetes mellitus is taught to take NPH insulin at 5 p.m. each day. The client should be instructed that the greatest risk of hypoglycemia will occur at about what time?
- A. 11 a.m., shortly before lunch.
- B. 1 p.m., shortly after lunch.
- C. 6 p.m., shortly after dinner.
- D. 1 a.m., while sleeping.
Correct Answer: D
Rationale: NPH insulin peaks 4–12 hours after administration (around 9 p.m. to 5 a.m.), with the greatest hypoglycemia risk overnight, such as at 1 a.m.
A client with cancer develops superior vena cava syndrome (SVCS). Which of the following symptoms should the nurse assess for?
- A. Facial swelling and dyspnea.
- B. Lower extremity edema.
- C. Abdominal distension.
- D. Flank pain.
Correct Answer: A
Rationale: SVCS obstructs venous return, causing facial swelling and dyspnea due to compression of the superior vena cava, which the nurse should prioritize in assessment.