Nokea
A client who is admitted with an above-the-knee amputation tells the nurse that his foot hurts and itches. Which response by the nurse indicates understanding of phantom limb pain?
- A. The pain will go away in a few days.
- B. The pain is due to peripheral nervous system interruptions. I will get you some pain medication.
- C. The pain is psychological because your foot is no longer there.
- D. The pain and itching are due to the infection you had before the surgery.
Correct Answer: B
Rationale: Phantom limb pain results from peripheral nervous system interruptions, and offering pain medication addresses the client's discomfort appropriately.
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The nurse is precepting a student nurse on an orthopedic floor. The student nurse needs to insert an indwelling catheter into a male client. Which of the following statements by the student nurse are correct regarding insertion of the catheter? Select all that apply.
- A. I need to establish an aseptic field.
- B. I will place the client in the supine position.
- C. I will lubricate the tip of the catheter with sterile lubricant included in the tray.
- D. I will inflate the catheter balloon with 5 cc of sterile water.
Correct Answer: A,B,C
Rationale: Aseptic technique, supine positioning, and sterile lubrication are correct for catheter insertion. Inflating the balloon with 5 cc is incorrect, as most catheters require 10 cc of sterile water for balloon inflation.
A client receiving high doses of hydromorphone (Dilaudid®) develops acute respiratory depression with a drop in blood pressure. Which of the following treatments is most indicated?
- A. Naloxone
- B. Naproxen
- C. Flumazenil
- D. Nortriptyline
Correct Answer: A
Rationale: Naloxone (A) reverses opioid-induced respiratory depression. Naproxen (B), flumazenil (C), and nortriptyline (D) are not appropriate.
The nurse is caring for an elderly client who presents to the ED with poor appetite, confusion, and weakness. Lab work is ordered for the client. The nurse should immediately notify the health care provider for which lab result?
- A. chloride 99 mEq/L
- B. calcium 9.4 mg/dL
- C. sodium 118 mEq/L
- D. potassium 4.2 mEq/L
Correct Answer: C
Rationale: Severe hyponatremia (sodium 118 mEq/L) can cause confusion and weakness and requires immediate provider notification. Other values are within normal ranges.
The nurse administers ciproflaxin to a client and then realizes that the client is allergic to the medication. What nursing action is the priority for this client?
- A. induce vomiting
- B. obtain the client's vital signs
- C. complete an incident report
- D. notify the health care provider
Correct Answer: D
Rationale: Notifying the health care provider is the priority to initiate immediate management of a potential allergic reaction, followed by monitoring and reporting.
A client with primary sclerosing cholangitis has received a liver transplant. The nurse should give priority to assessing the client for complications. Which findings are associated with an acute rejection of the new liver?
- A. Increased jaundice and prolonged prothrombin time
- B. Fever and foul-smelling bile drainage
- C. Abdominal distention and clay-colored stools
- D. Increased uric acid and increased creatinine
Correct Answer: A
Rationale: Increased jaundice and prolonged prothrombin time indicate liver dysfunction, consistent with acute liver transplant rejection.