Nokea
A client receives morphine for postoperative pain. Which of the following assessments should the nurse include in the client's plan of care?
- A. Take apical heart rate after each dose of morphine.
- B. Assess urinary output every 8 hours.
- C. Assess mental status every shift.
- D. Check for pedal edema every 4 hours.
Correct Answer: C
Rationale: Morphine can cause sedation and altered mental status, requiring regular assessment to monitor for adverse effects.
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A client has a prescription to have a set of arterial blood gases (ABGs) drawn, and the intended site is the radial artery. The nurse ensures that which is positive before the ABGs are drawn?
- A. Allen test
- B. Turner's sign
- C. Babinski reflex
- D. Brudzinski's sign
Correct Answer: A
Rationale: The Allen test is performed before drawing ABGs. Both the radial and ulnar arteries are occluded and then pressure on the ulnar artery is released. Observation is made in the distal circulation. If the results are positive, then the client has adequate circulation and the radial artery may be used. Turner's sign is the bluish discoloration of the flanks and is indicative of pancreatitis. The Babinski reflex is checked by stroking upward on the sole of the foot. Brudzinski's sign tests for nuchal rigidity by bending the head down toward the chest.
Which nursing action is most essential for the hospitalized client with a new tracheostomy?
- A. Decrease secretions
- B. Provide client teaching regarding tracheostomy care
- C. Relieve anxiety related to the tracheostomy
- D. Maintain a patent airway
Correct Answer: D
Rationale: Maintaining a patent airway is the most critical action for a client with a new tracheostomy to ensure adequate oxygenation. Other actions are important but secondary to airway patency.
The nurse is assessing a client with a suspected tension pneumothorax. Which of the following findings is most indicative of this condition?
- A. Symmetrical chest movement.
- B. Tracheal deviation to the affected side.
- C. Dull percussion note on the affected side.
- D. Absent breath sounds on the affected side.
Correct Answer: B,D
Rationale: Tracheal deviation to the unaffected side and absent breath sounds on the affected side are hallmark signs of tension pneumothorax due to mediastinal shift and lung collapse.
A client is admitted with a diagnosis of acute pancreatitis. The nurse should expect the client to report which of the following symptoms?
- A. Pain radiating to the right shoulder.
- B. Epigastric pain radiating to the back.
- C. Right lower quadrant pain.
- D. Diffuse lower abdominal pain.
Correct Answer: B
Rationale: Acute pancreatitis typically causes epigastric pain that radiates to the back due to pancreatic inflammation.
The nurse is assessing a 55-year-old client with chronic obstructive pulmonary disease. The client weighs 200 lb and is 6 feet tall. Using the diagram shown here, the nurse should record in the health history that the client's chest is:
- A. Barrel-shaped
- B. Muscular
- C. Normal for the client's age, height, and weight
- D. Showing the effects of long-term use of bronchodilators
Correct Answer: A
Rationale: A barrel-shaped chest is characteristic of chronic obstructive pulmonary disease due to hyperinflation of the lungs, which is likely in this client. The client's weight and height suggest a normal body habitus, not a muscular chest, and bronchodilator use does not directly cause this chest shape.