Nokea
A client reports having pain in his casted left arm that is unrelieved by pain medication. The nurse assesses the arm and notes that the fingers are swollen and difficult to separate. Which action is most appropriate for the nurse to take at this time?
- A. Administer morphine 2 mg intravenously
- B. Apply an ice bag to the fingers to relieve pain
- C. Elevate the arm on two pillows and reassess in 30 minutes
- D. Call the physician to report swelling and pain
Correct Answer: D
Rationale: Swelling and unrelieved pain in a casted arm suggest possible compartment syndrome, requiring immediate physician notification. Elevating the arm or applying ice may help but is secondary to reporting.
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The nurse is caring for a client with a history of seizures. Which precaution should be implemented?
- A. Keep the bed in the highest position.
- B. Ensure suction equipment is at the bedside.
- C. Allow the client to ambulate without assistance.
- D. Remove all padded side rails.
Correct Answer: B
Rationale: Suction equipment is essential to maintain airway patency during a seizure, a critical safety precaution.
A client with a history of peptic ulcer disease is prescribed ranitidine (Zantac). The nurse should instruct the client to take the medication:
- A. With meals
- B. At bedtime
- C. Before breakfast
- D. After exercise
Correct Answer: B
Rationale: Ranitidine, an H2 receptor blocker, is most effective when taken at bedtime to reduce nighttime acid production and promote ulcer healing.
The nurse finds a sealed container of I.V. 50% dextrose in a waste bin on the nursing unit. The nurse should:
- A. Leave it where found and notify risk management.
- B. Send it to the pharmacy.
- C. File an incident report.
- D. Discard it in a sharps container.
Correct Answer: C
Rationale: Filing an incident report addresses the improper disposal of a medication, ensuring investigation and prevention of future errors.
A client has a viral (coxsackie B) or trypanosomal (parasite) infection. The nurse should further assess the client for:
- A. Myocarditis.
- B. Myocardial infarction.
- C. Renal failure.
- D. Liver failure.
Correct Answer: A
Rationale: Coxsackie B and trypanosomal infections are associated with myocarditis, an inflammation of the heart muscle, which requires further assessment.
A client diagnosed with glomerulonephritis and at risk of developing acute kidney injury should be monitored for which complication?
- A. Bradycardia
- B. Hypertension
- C. Decreased cardiac output
- D. Decreased central venous pressure
Correct Answer: B
Rationale: Acute kidney injury caused by glomerulonephritis is classified as intrinsic or intrarenal failure. This form of acute kidney injury is commonly manifested by hypertension, tachycardia, oliguria, lethargy, edema, and other signs of fluid overload. Acute kidney injury from prerenal causes is characterized by decreased blood pressure or a recent history of the same, tachycardia, and decreased cardiac output and central venous pressure. Bradycardia is not part of the clinical picture for renal failure.