Nokea
A client is eligible for patient-controlled analgesia (PCA) when:
- A. A family member is able to assist with self-dosing.
- B. There is a court-appointed advocate to assist with self-dosing.
- C. The client has the ability to self-dose.
- D. There is a nurse to assist with self-dosing.
Correct Answer: C
Rationale: PCA requires the client to have the cognitive and physical ability to self-dose, ensuring safe and effective pain management.
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A client has returned from the cardiac catheterization laboratory after a balloon valvuloplasty for mitral stenosis. Which of the following requires immediate nursing action?
- A. A low, grade 1 intensity mitral regurgitation murmur.
- B. SpO2 is 94% on 2 liters of oxygen via nasal cannula.
- C. The client has become more somnolent.
- D. Urine output has decreased from 60 mL/hour to 40 mL over the last hour.
Correct Answer: C
Rationale: Increased somnolence may indicate neurological complications (e.g., stroke) post-valvuloplasty, requiring immediate action. Other findings are less urgent.
The physician orders intestinal decompression with a Cantor tube for a client with an intestinal obstruction. In order to determine effectiveness of intestinal decompression the nurse should evaluate the client to determine if:
- A. Fluid and gas have been removed from the intestine.
- B. The client has had a bowel movement.
- C. The client's urinary output is adequate.
- D. The client can sit up without pain.
Correct Answer: A
Rationale: The effectiveness of a Cantor tube is determined by the removal of fluid and gas from the intestine, relieving the obstruction. Bowel movements, urinary output, or sitting up without pain are not direct indicators of decompression success. CN: Physiological adaptation; CL: Evaluate
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.
The nurse is teaching a client about managing osteoarthritis pain. Which non-pharmacologic intervention should be included?
- A. Apply ice packs for 30 minutes at a time.
- B. Maintain a high-protein diet.
- C. Use a heating pad on high setting.
- D. Perform gentle range-of-motion exercises.
Correct Answer: D
Rationale: Gentle range-of-motion exercises maintain joint mobility and reduce stiffness in osteoarthritis.
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.