Nokea
A client tells the nurse that she has had sexual contact with someone whom she suspects has genital herpes. Which of the following instructions should the nurse give the client in response to this information?
- A. Anticipate lesions within 25 to 30 days.
- B. Continue sexual activity unless lesions are present.
- C. Report any difficulty urinating.
- D. Drink extra fluids to prevent lesions from forming.
Correct Answer: C
Rationale: Difficulty urinating can indicate herpes-related urinary retention, a serious complication requiring medical attention.
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The nurse is caring for a client who has just undergone a total knee replacement. Which of the following interventions is most important in the immediate postoperative period?
- A. Encourage weight-bearing on the affected leg.
- B. Apply ice packs to the surgical site.
- C. Keep the leg in a dependent position.
- D. Limit range-of-motion exercises.
Correct Answer: B
Rationale: Applying ice packs reduces swelling and pain post-knee replacement, promoting recovery.
Which of the following would be true regarding medication reconciliation? Select all that apply.
- A. Medication reconciliation is a Joint Commission National Patient Safety Goal.
- B. Medication reconciliation is designed to obtain and communicate an accurate list of a client's home medications across the continuum of care.
- C. Only nurses or health care providers can be involved in medication reconciliation.
- D. Medications are considered reconciled if a medication order exists that is therapeutically equivalent to the one prior to admission.
- E. A medication is considered to be any medication ordered by a physician.
Correct Answer: A, B, D
Rationale: Medication reconciliation is a Joint Commission goal to ensure accurate medication lists across care transitions. Equivalent medications are reconciled, but not all staff are limited to nurses/providers, and not all medications are physician-ordered.
After abdominal surgery, a client has an order for meperidine (Demerol) I.M. 100 mg every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking meperidine every 4 hours for the past 48 hours, but she tells the nurse that the meperidine is no longer lasting 4 hours and she needs to have it every 3 hours. Which of the following nursing actions is most appropriate?
- A. Realizing that the client is developing tolerance to the meperidine, the nurse administers the meperidine every 3 hours.
- B. The nurse urges the client to take the acetaminophen with codeine to prevent addiction to the meperidine.
- C. The nurse requests an order from the physician to change the dose to an equianalgesic dose of morphine.
- D. The nurse encourages the client to do relaxation exercises to provide distraction from the pain.
Correct Answer: C
Rationale: Increasing frequency suggests tolerance; switching to an equianalgesic dose of morphine may provide better pain control without escalating doses.
The nurse is assessing a client's disposable closed chest drainage system at the beginning of the shift and notes continuous bubbling in the water-seal chamber. What should the nurse determine is the possible cause of the bubbling?
- A. The system is intact.
- B. A pneumothorax is resolving.
- C. The suction to the system is shut off.
- D. There is an air leak somewhere in the system.
Correct Answer: D
Rationale: Continuous bubbling in the water-seal chamber through both inspiration and expiration indicates that air is leaking into the system. A resolving pneumothorax would show intermittent bubbling in the water-seal chamber with respiration. Shutting the suction off to the system stops bubbling in the suction control chamber, but does not affect the water-seal chamber.
A client with a history of heart failure is admitted with pulmonary edema. The nurse should administer which of the following medications as prescribed? Select all that apply.
- A. Furosemide (Lasix).
- B. Digoxin (Lanoxin).
- C. Nitroglycerin.
- D. Morphine.
- E. Aspirin.
Correct Answer: A, C, D
Rationale: Furosemide reduces fluid overload, nitroglycerin decreases preload, and morphine relieves anxiety and preload in pulmonary edema.