Nokea
A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
- A. Advil
- B. Anasaid
- C. Clinocil
- D. Colace
Correct Answer: D
Rationale: Colace is a stool softener that acts by pulling more water into the bowel lumen, making the stool soft and easier to evacuate.
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Pressure ulcers usually occur:
- A. When clients are left in one position in bed for extended periods of time
- B. When clients are underweight
- C. When clients are overweight
- D. Only in underweight and overweight clients
Correct Answer: A
Rationale: Pressure ulcers occur over bony prominences due to decreased circulation from prolonged immobility, not specifically related to body weight.
The nurse is teaching the client, who is 24 hours post abdominal surgery, how to use an IS. Which instructions should the nurse include in the teaching? Select all that apply.
- A. Inhale slowly and deeply through mouth
- B. Seal lips tightly around mouthpiece
- C. After inhaling, hold breath for 2 to 3 seconds
- D. Sit with the HOB down and bed almost flat
- E. Splint the incision with pillows
- F. Exhale forcefully, fast, and hard
Correct Answer: A,B,C,E
Rationale: A: Deep inhalation maximizes alveolar inflation. B: Sealing prevents air leaks. C: Holding breath enhances lung expansion. E: Splinting reduces pain, aiding inhalation. D: High Fowler's position is optimal. F: Slow exhalation prevents hyperventilation.
A client's postoperative pain seems to be getting worse instead of better. When the nurse asks the client, 'Why do you think it's getting worse?' the client replies, 'My wife died last month. It's all I can think about.' The nurse must now consider:
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct Answer: D
Rationale: The client's grief over his wife's death is likely exacerbating his pain perception, requiring grief and loss interventions to address the affective component.
The nurse is taking the client's temperature. What should the nurse do to correctly obtain the temperature with a tympanic thermometer?
- A. Ensure that the probe tip seals the ear canal prior to taking a temperature.
- B. Irrigate the ear canal with sterile saline before obtaining the temperature.
- C. When inserting the thermometer in the adult ear, pull downward on the pinna.
- D. Check to be sure that the client does not have any tympanostomy tubes in place.
Correct Answer: A
Rationale: A: Sealing the ear canal ensures accurate readings. B: Irrigation is unnecessary and affects results. C: The pinna is pulled upward in adults. D: Tympanostomy tubes don't affect readings after initial placement.
People who live in poverty are most likely to obtain health care from:
- A. their primary care physician (family doctor)
- B. a neighborhood clinic
- C. specialists
- D. Emergency Departments or urgent care centers
Correct Answer: D
Rationale: Economic barriers often lead those in poverty to seek care from Emergency Departments or urgent care centers, which are more accessible than primary care or specialists.