Nokea
A client is being discharged with nasal packing in place. The nurse should instruct the client to:
- A. Perform frequent mouth care.
- B. Use normal saline nose drops daily.
- C. See normal enough with mouth mouth.
- D. Gargle every 4 hours with salt water.
Correct Answer: A
Rationale: Frequent mouth care prevents dryness and infection due to mouth breathing with nasal packing. Saline drops are not needed with packing in place. The third option is unclear. Gargling is not routinely required.
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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.
A client has an amylase level of 450 units/L and lipase level of 659 units/L. The client has mid-epigastric pain with nausea. What assessment helps the nurse to determine severity of the client's condition?
- A. Ranson's criteria.
- B. Vital signs.
- C. Urine output.
- D. Glasgow Coma Scale.
Correct Answer: A
Rationale: Ranson's criteria (A) assess pancreatitis severity using clinical and lab parameters like age, glucose, and white blood cell count. Vital signs (B) and urine output (C) are general but less specific. Glasgow Coma Scale (D) is for neurological assessment, not pancreatitis severity.
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 nurse is observing a student nurse administer eyedrops, as shown in the figure. What should the nurse instruct the student to do?
- A. Move the dropper to the inner canthus.
- B. Have the client raise her eyebrows.
- C. Administer the drops in the center of the lower lid.
- D. Have the client squeeze both eyes after administering the drops.
Correct Answer: C
Rationale: The student has positioned the dropper and the client correctly to prevent injury to the client's eye. The student should administer the drops in the center of the lower lid. Following administration of the eyedrops, the client should blink her eyes to distribute the medication; squeezing or rubbing her eyes might cause the medication to drip out of the eye.
A client with terminal cancer expresses fear of dying alone. The nurse's most therapeutic response is:
- A. You won't be alone; we'll ensure someone is with you.
- B. Everyone dies alone, but it's not something to fear.
- C. Let's focus on keeping you comfortable instead.
- D. Have you considered spiritual counseling?
Correct Answer: A
Rationale: Assuring the client that someone will be present addresses their fear directly, providing emotional reassurance and support.