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A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client?
- A. Observing the client at regular intervals for opioid addiction.
- B. Encouraging the client to reduce analgesic use and tolerate the pain.
- C. Evaluating pain control at least every 2 hours.
- D. Increasing the amount of morphine if the client does not administer the medication.
Correct Answer: C
Rationale: Regularly evaluating pain control ensures adequate relief while monitoring for side effects, a priority in PCA management.
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The nurse is teaching a caregiver how to administer an injection of enoxaparin. Which statement, if made by the caregiver, would require further teaching?
- A. "I will give this injection in the abdomen."
- B. "I should give this injection at a 30 degree angle."
- C. "Acetaminophen is safe while taking this medication for any aches or pains."
- D. "A soft toothbrush should be used while taking this medicine."
Correct Answer: B
Rationale: Enoxaparin is administered subcutaneously at a 90-degree angle, not 30 degrees, to ensure proper absorption.
Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's disease?
- A. To cure the disease.
- B. To stop progression of the disease.
- C. To begin preparations for terminal care.
- D. To maintain optimal body function.
Correct Answer: D
Rationale: Maintaining optimal body function is realistic, focusing on symptom management and quality of life. Parkinson's is incurable, progression cannot be stopped, and terminal care is premature for most clients.
The nurse is developing a plan of care for the client with viral hepatitis. The nurse should instruct the client to:
- A. Obtain adequate bed rest.
- B. Increase fluid intake.
- C. Follow a high-protein diet.
- D. Avoid carbohydrates.
Correct Answer: A
Rationale: Adequate bed rest (A) supports recovery in viral hepatitis by reducing metabolic demands. Increased fluids (B) are helpful but secondary. High-protein (C) or avoiding carbohydrates (D) is not indicated.
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will:
- A. Develop joint mobility.
- B. Develop muscle strength.
- C. Develop cognition.
- D. Develop mood elevation.
Correct Answer: C
Rationale: Developing cognition is not realistic, as MS can cause cognitive decline that is not typically reversible. Improving mobility, strength, and mood are achievable with therapy and support.
How often should the postoperative client's temperature be assessed during the first 24 hours after surgery?
- A. Every 2 hours.
- B. Every 4 hours.
- C. Every 6 hours.
- D. Every 8 hours.
Correct Answer: B
Rationale: Assessing temperature every 4 hours in the first 24 hours detects fever early, indicating potential infection or other complications.