Nokea
A client on peritoneal dialysis reports cloudy effluent. The nurse should:
- A. Continue the exchange.
- B. Notify the physician.
- C. Increase dwell time.
- D. Administer pain medication.
Correct Answer: B
Rationale: Cloudy effluent suggests peritonitis, requiring immediate medical attention.
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The nurse is assessing a client's nutritional status preoperatively. Which of the following observations would indicate poor nutrition in a 5-foot 7-inch female client who is 21 years of age?
- A. Poor posture.
- B. Little mass.
- C. Dull expression.
- D. Weight of 128 lb (58.1 kg).
Correct Answer: B
Rationale: Little mass in a 5'7' female suggests low body weight or muscle wasting, indicative of poor nutrition. A weight of 128 lb is within a healthy range, and poor posture or dull expression are less specific to nutritional status.
The physician orders Morphine Sulfate 2-4 mg IV push every 2 hours prn pain for a client who has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing change with packing at 10 AM, the nurse assesses the client's pain level as 1 on a scale of 0 = no pain to 10 = the worst pain. The client is awake and oriented and vital signs are within normal limits. The nurse reviews the pain medication record (see chart). The nurse should:
- A. Perform the dressing change.
- B. Administer Morphine 2 mg IV before the dressing change.
- C. Administer Morphine 4 mg IV after the dressing change.
- D. Call the physician for a new medication order.
Correct Answer: A
Rationale: With a pain level of 1, the client does not require morphine (prn order). Performing the dressing change is appropriate, as the pain is minimal and manageable.
In which areas of the United States is the incidence of tuberculosis highest?
- A. Rural farming areas.
- B. Inner-city areas.
- C. Areas where clean water standards are low.
- D. Suburban areas with significant industrial pollution.
Correct Answer: B
Rationale: Inner-city areas have higher tuberculosis incidence due to crowding, poverty, and limited healthcare access. Rural, low-water-standard, and suburban areas have lower rates.
A client with diverticular disease is receiving psyllium hydrophilic mucilloid (Metamucil). The drug has been effective when the client tells the nurse that he:
- A. Passes stool without cramping.
- B. Does not have diarrhea any longer.
- C. Is not as anxious as he was.
- D. Does not expel gas like he used to.
Correct Answer: A
Rationale: Psyllium (Metamucil) is effective when the client passes stool without cramping, indicating improved bowel regularity and reduced irritation. Absence of diarrhea, anxiety, or gas are not primary indicators of its effectiveness. CN: Pharmacological and parenteral therapies; CL: Evaluate
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) fosters therapeutic communication and addresses emotional needs. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic and unhelpful.