Nokea
A client states that she is afraid of receiving vitamin B12 injections because of potential toxic effects, which is the nurse's best response to relieve these fears?
- A. Vitamin B12 will cause ringing in the ears before a toxic level is reached.'
- B. Vitamin B12 may cause a very mild rash initially.'
- C. Vitamin B12 may cause mild nausea but nothing toxic.'
- D. Vitamin B12 is generally free of toxicity because it is water-soluble.'
Correct Answer: D
Rationale: Vitamin B12 is a water-soluble vitamin, and excess amounts are excreted in urine, making toxicity rare. This response reassures the client by addressing her fear of toxic effects accurately. The other responses are incorrect, as B12 does not typically cause ringing in the ears, rash, or nausea as signs of toxicity.
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A nurse is assessing a client when she returns from same-day surgery for a dilatation and curettage. The nurse checks preoperative vital signs at 8:30 a.m. to compare them with the current vital signs at 10:30 p.m. (see chart). What should the nurse do fi rst?
- A. Call the physician for pain medication.
- B. Cover the client with warmed blankets.
- C. Administer oxygen at 4 L/minute.
- D. Increase the I.V. fl uid rate.
Correct Answer: B
Rationale: The client’s body temperature dropped 2.5° F from the preoperative to postoperative phase. The client lost heat during the preoperative period. The client has not had time to regain the heat she has lost and should not be discharged postoperatively until her postoperative vital signs, which include body temperature, are closer to her preoperative vital signs. The client’s pulse rate, respiratory rate, and blood pressure have compensated according to the client’s hypothermic state and will refl ect changes as the client warms up. There are no indications that the client needs more pain medication, oxygen, or I.V. fl uids.
Which of the following techniques does the nurse avoid when changing a client's position in bed if the client has hemiparalysis?
- A. Rolling the client onto the side.
- B. Sliding the client to move up in bed.
- C. Lifting the client when moving the client up in bed.
- D. Having the client help lift off the bed using a trapeze.
Correct Answer: B
Rationale: Sliding the client can cause shear injuries to the skin, especially in hemiparalysis with reduced sensation. Rolling, lifting, or using a trapeze (if feasible) are safer techniques.
As part of the client's discharge planning after a subtotal gastrectomy, the nurse has identified Imbalanced nutrition: Less than body requirements as a major nursing diagnosis. To help the client meet nutritional goals at home, the nurse should develop a plan of care that includes which of the following interventions?
- A. Instruct the client to increase the amount eaten at each meal.
- B. Encourage the client to eat smaller amounts more frequently.
- C. Explain that if vomiting occurs after a meal, nothing more should be eaten that day.
- D. Inform the client that bland foods are typically less nutritional and should be used minimally.
Correct Answer: B
Rationale: Smaller, frequent meals help prevent dumping syndrome and ensure adequate nutrition post-gastrectomy. Large meals, fasting after vomiting, or avoiding bland foods are not appropriate.
Which symptom suggests a complication post-renal surgery?
- A. Urine output of 25 mL/hour.
- B. Temperature of 99°F.
- C. Mild incisional pain.
- D. Clear urine.
Correct Answer: A
Rationale: Low urine output (25 mL/hour) may indicate obstruction or renal impairment.
A client with rheumatoid arthritis states, 'I can't do my household chores without becoming tired. My knees hurt whenever I walk.' Which nursing diagnosis would be most appropriate?
- A. Activity intolerance related to fatigue and pain.
- B. Self-care deficit related to increasing joint pain.
- C. Selective coping related to chronic pain.
- D. Disturbed body image related to fatigue and joint pain.
Correct Answer: A
Rationale: The client's symptoms of fatigue and knee pain directly contribute to activity intolerance, making this the most appropriate nursing diagnosis.