Nokea
A client scheduled for a cholecystectomy expresses fear about postoperative pain. Which nursing action is most appropriate?
- A. Administer preoperative analgesics as ordered.
- B. Teach the client about pain management options.
- C. Reassure the client that pain is minimal after surgery.
- D. Refer the client to a pain management specialist.
Correct Answer: B
Rationale: Teaching the client about pain management options, such as PCA or oral analgesics, empowers them to understand and cope with postoperative pain, reducing anxiety. Administering analgesics may not be ordered preoperatively, and reassurance without education is inadequate.
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A client with renal calculi has a stent placed. The nurse should teach:
- A. Report blood in urine.
- B. Avoid all activity.
- C. Remove the stent at home.
- D. Expect no discomfort.
Correct Answer: A
Rationale: Blood in urine may indicate stent issues, requiring medical attention.
An elderly client had posterior packing inserted to control a severe nosebleed. After insertion of the packing, the client should be made to be removed for which of the following complications?
- A. Vertigo.
- B. Bell's palsy.
- C. Hypoventilation.
- D. Loss of gag reflex.
Correct Answer: C
Rationale: Posterior packing can obstruct the airway, leading to hypoventilation, a serious complication. Vertigo, Bell's palsy, and loss of gag reflex are not directly associated with posterior packing.
The client's blood urea nitrogen (BUN) concentration is elevated in acute renal failure. What is the likely cause of this finding?
- A. Fluid retention.
- B. Hemolysis of red blood cells.
- C. Below-normal metabolic rate.
- D. Reduced renal blood flow.
Correct Answer: D
Rationale: Reduced renal blood flow impairs urea excretion, causing elevated BUN levels in acute renal failure.
Which finding indicates effective hemodialysis?
- A. Decreased BUN.
- B. Increased potassium.
- C. Weight gain.
- D. Hypotension.
Correct Answer: A
Rationale: Decreased BUN indicates effective removal of waste products.
Which of the following is an assessment finding associated with internal bleeding with disseminated intravascular coagulation?
- A. Bradycardia.
- B. Hypertension.
- C. Increasing abdominal girth.
- D. Petechiae.
Correct Answer: C
Rationale: Internal bleeding in DIC can cause blood accumulation in the abdominal cavity, leading to increasing abdominal girth. Bradycardia and hypertension are not typical, and petechiae are associated with cutaneous bleeding.