Nokea
A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
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A client with thyrotoxicosis says to the nurse, 'I am so irritable. I am having problems at work because I lose my temper very easily.' Which of the following responses by the nurse would give the client the most accurate explanation of her behavior?
- A. Your behavior is caused by your not following the medical regimen.'
- B. Your behavior is caused by the effects of the disease on your thyroid.'
- C. Your behavior is caused by your not accepting your diagnosis.'
- D. Your behavior is caused by the effects of the disease on your emotional stability.'
Correct Answer: B
Rationale: Thyrotoxicosis, due to excess thyroid hormone, increases metabolism and can affect the nervous system, leading to irritability and emotional lability. This explains the client's behavior as a direct result of the disease's impact on thyroid function.
A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct Answer: A
Rationale: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.
The nurse is developing a discharge teaching plan for a client who underwent a repair of abdominal aortic aneurysm 4 days ago. The nurse reviews the client's chart for information about the client's history. Key findings are noted in the chart below. Based on the data and expected outcomes, which should the nurse emphasize in the teaching plan?
- A. Food intake
- B. Fluid volume
- C. Skin integrity
- D. Tissue perfusion
Correct Answer: D
Rationale: Post-AAA repair, tissue perfusion is critical to ensure graft patency and prevent ischemia in the lower extremities or organs. Teaching should emphasize signs of poor perfusion (e.g., pain, pallor, pulselessness) and follow-up care. Food, fluid, and skin integrity are less urgent.
The nurse has provided medication instructions to a client who has been prescribed a fentanyl transdermal patch. Which of the following statements, if made by the client, would indicate a correct understanding of the instructions? Select all that apply.
- A. I may still need pain medication while this patch is applied.
- B. If the patch comes loose, I may reinforce it with a piece of tape.
- C. I can apply heat to the patch site to increase the pain relief.
- D. I should remove this patch while I am sleeping.
- E. The patch will need to be changed every 72 hours.
Correct Answer: A,B,E
Rationale: A: Breakthrough pain may require additional medication. B: Taping a loose patch is acceptable. E: Fentanyl patches are typically changed every 72 hours. C is incorrect because heat can increase absorption and risk toxicity. D is incorrect as patches are not removed during sleep.
What is the nurse's priority for a client with Guillain-Barré syndrome?
- A. Monitor respiratory function.
- B. Assess pain levels.
- C. Check skin integrity.
- D. Evaluate bowel function.
Correct Answer: A
Rationale: Monitoring respiratory function is the priority due to potential respiratory muscle weakness in Guillain-Barré syndrome.