Nokea
A client with a C3 spinal cord injury experiences autonomic hyperreflexia. After placing the client in high Fowler's position, the nurse's next action should be to:
- A. Notify the physician
- B. Make sure the catheter is patent
- C. Administer an antihypertensive
- D. Provide supplemental oxygen
Correct Answer: B
Rationale: Autonomic hyperreflexia is often triggered by bladder distension; ensuring a patent catheter addresses the most common cause and can resolve symptoms.
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Which nursing assessment indicates that involutional changes have occurred in a client who is 3 days postpartum?
- A. The fundus is firm and 3 finger widths below the umbilicus.
- B. The client has a moderate amount of lochia serosa.
- C. The fundus is firm and even with the umbilicus.
- D. The uterus is approximately the size of a small grapefruit.
Correct Answer: A
Rationale: A firm fundus 3 finger widths below the umbilicus by day 3 postpartum indicates normal uterine involution, as the uterus shrinks progressively after delivery.
The nurse is preparing to transfer a client from the ED to the orthopedic unit. She knows that adhering to the hospital policy for client handoffs best ensures which of the following?
- A. privacy
- B. Patient's Bill of Rights
- C. continuity of care
- D. case management
Correct Answer: C
Rationale: Proper handoffs ensure continuity of care by transferring critical information accurately between care teams.
The nurse is assisting a client with a colostomy irrigation. The client is positioned on the toilet and has removed the colostomy pouch, and the irrigation bag is filled with 1000 mL of warm water. Place the following actions (in Roman numerals) in the correct order from first to last
- A. Allow 15 to 20 minutes for evacuation and then fold the sleeve, secure it, and leave it in place for 30 to 45 minutes before removing it.
- B. Allow the solution to flow in for 5 to 10 minutes and then clamp the tubing and close the top of the irrigation sleeve.
- C. Apply gloves, lubricate the cone tip, and insert it into the stoma, holding it securely.
- D. Apply the irrigation sleeve over the stoma.
- E. Hang the irrigation solution with the bottom of the bag being 20 inches above the stoma.
Correct Answer: E,D,C,B,A
Rationale: The correct order is: Hang the irrigation solution (V), apply the irrigation sleeve (IV), insert the cone tip (III), allow solution to flow (II), and allow evacuation (I), ensuring proper setup and procedure.
The nurse is caring for a client scheduled for removal of the pituitary gland. The nurse should be particularly alert for:
- A. Nasal congestion
- B. Abdominal tenderness
- C. Muscle tetany
- D. Oliguria
Correct Answer: D
Rationale: Oliguria may indicate diabetes insipidus, a common complication after pituitary surgery due to antidiuretic hormone deficiency.
The nurse is caring for a client with bipolar disorder. The client has been manipulating some of the staff and other clients in order to get her way. Which actions by the nurse are appropriate in managing this client? Select all that apply.
- A. giving support when the client exhibits positive behaviors
- B. setting clear limits and communicating expected behaviors
- C. role playing with the client to demonstrate appropriate behaviors
- D. treating the client more like a friend in order to show respect for her as a person
- E. giving the client small gifts, such as extra dessert, in order to encourage appropriate behavior
Correct Answer: A,B,C
Rationale: Appropriate actions include reinforcing positive behaviors (A), setting clear limits (B), and role-playing (C) to promote appropriate interactions. Treating as a friend (D) or giving gifts (E) blurs boundaries and encourages manipulation.