Nokea
A client on the post-op floor underwent surgery 4 days ago. The night nurse reports to the nurse coming on to dayshift that the client complained all night of pain, even though she received every dose of prescribed pain medication. The client currently rates the pain at a 10 out of 10. The day shift nurse should first
- A. call the physician and ask her to prescribe a different medication.
- B. work with the client on alternative pain relief measures such as guided imagery.
- C. administer the next dose of pain medication, but observe the client swallow it to ensure she is really taking the medication.
- D. complete a full head-to-toe assessment on the client.
Correct Answer: D
Rationale: Persistent severe pain post-op suggests a complication (e.g., infection, hemorrhage). A full assessment is the priority to identify the cause before adjusting treatment.
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The nurse is discharging a client with asthma who has a prescription for zafirlukast (Accolate). Which comment by the client would indicate a need for further teaching?
- A. I should take this medication with meals.'
- B. I need to report flulike symptoms to my doctor.'
- C. My doctor might order liver tests while I'm on this drug.'
- D. If I'm already having an asthma attack, this drug will not stop it.'
Correct Answer: A
Rationale: Zafirlukast should be taken on an empty stomach for better absorption. The other statements are correct: flulike symptoms and liver monitoring are relevant, and zafirlukast is not a rescue medication.
A home health nurse is planning for her daily visits. Which client should the home health nurse visit first?
- A. A client with AIDS being treated with Foscarnet
- B. A client with a fractured femur in a long leg cast
- C. A client with laryngeal cancer with a laryngectomy
- D. A client with diabetic ulcers to the left foot
Correct Answer: A
Rationale: Foscarnet requires monitoring for toxicity, making this client a priority.
The nurse is assessing an older adult. The client does not appear to always understand the questions, sometimes answering incorrectly, and stares at the nurse's mouth rather than the nurse's eyes when the nurse is speaking. The client answers in an unusually loud voice. Which of the following impairments should the nurse suspect?
- A. Hearing impairment
- B. Cognitive impairment
- C. Vision impairment
- D. Anxiety
Correct Answer: A
Rationale: Staring at the mouth, answering loudly, and misunderstanding questions suggest hearing impairment (A). Cognitive impairment (B), vision impairment (C), and anxiety (D) do not typically present with these specific behaviors.
The physician has ordered Vancocin (vancomycin) 500 mg IV every 6 hours for a client with MRSA. The medication should be administered:
- A. IV push
- B. Over 15 minutes
- C. Over 30 minutes
- D. Over 60 minutes
Correct Answer: D
Rationale: Vancomycin should be infused over at least 60 minutes to prevent adverse reactions such as red man syndrome.
The mother of a 9-year-old with asthma has brought an electric CD player for her son to listen to while he is receiving oxygen therapy. The nurse should:
- A. Explain that he does not need the added stimulation
- B. Allow the player, but ask him to wear earphones
- C. Tell the mother that he cannot have items from home
- D. Ask the mother to bring a battery-operated CD instead
Correct Answer: B
Rationale: Allowing the CD player with earphones provides comfort without disturbing others or interfering with oxygen therapy.