Nokea
A client with a fractured femur has a BP of 140/94 mmHg and denies any history of HTN. Which of the following actions should the nurse take first?
- A. Request a prescription for an antihypertensive medication.
- B. Ask the client if they are having pain.
- C. Request a prescription for an antianxiety medication.
- D. Return in 30 minutes to recheck the client's BP.
Correct Answer: B
Rationale: The correct action is to ask the client if they are having pain. Pain can lead to temporary increases in blood pressure. Addressing pain as a potential cause is the initial step before considering medication adjustments. Requesting an antihypertensive medication or an antianxiety medication without assessing pain first would not address the immediate concern. Returning to recheck the BP can be done after addressing the potential pain issue.
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A client is 48 hours postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication?
- A. Impaired peristalsis of the intestines
- B. Infection at the surgical site
- C. Fluid overload
- D. Inadequate pain management
Correct Answer: A
Rationale: Gas pains in the periumbilical area postoperatively are often caused by impaired peristalsis and bowel function. Following abdominal surgery, it is common for peristalsis to be reduced due to surgical manipulation and anesthesia effects. This reduction in peristalsis can lead to the accumulation of gas in the intestines, resulting in gas pains. Infection at the surgical site (Choice B) would present with localized signs of infection such as redness, swelling, warmth, and drainage, rather than diffuse gas pains. Fluid overload (Choice C) would manifest with symptoms such as edema, increased blood pressure, and respiratory distress, not gas pains. Inadequate pain management (Choice D) may lead to increased discomfort, but it is not the primary cause of gas pains in the periumbilical area following a small bowel resection.
A healthcare professional is preparing to perform a sterile dressing change for a client. Which of the following actions should the healthcare professional plan to take?
- A. Don sterile gloves after opening sterile dressing supplies
- B. Set up the sterile field at waist level
- C. Consider the entire border of the sterile field as contaminated
- D. Place the cap of a sterile solution inside the sterile field
Correct Answer: B
Rationale: Setting up the sterile field at waist level is crucial to maintaining its sterility during a dressing change. Choice A is incorrect because sterile gloves should be worn after opening sterile dressing supplies to prevent contamination. Choice C is incorrect as the entire border of the sterile field should be considered contaminated to maintain sterility. Choice D is incorrect because the cap of a sterile solution should never be placed inside the sterile field to prevent contamination.
A client is 1-day postoperative and reports a pain level of 10 on a scale of 0 to 10. After reviewing the client's medication administration record, which of the following medications should be administered?
- A. Meperidine 75 mg IM
- B. Fentanyl 50 mcg/hr transdermal patch
- C. Morphine 2 mg IV
- D. Oxycodone 10 mg PO
Correct Answer: C
Rationale: Morphine IV is the most appropriate choice for severe postoperative pain due to its rapid onset and effectiveness. Meperidine is not preferred due to its potential side effects, and fentanyl patches are typically used for chronic pain, not acute postoperative pain. Oxycodone taken orally is not ideal for providing immediate relief in this situation.
A healthcare provider is caring for a client who has a heart murmur. The healthcare provider is preparing to auscultate the pulmonary valve. Over which of the following locations should the healthcare provider place the bell of the stethoscope?
- A. Second intercostal space at the left sternal border
- B. Fifth intercostal space at the midclavicular line
- C. Fourth intercostal space at the left sternal border
- D. Fifth intercostal space at the left anterior axillary line
Correct Answer: A
Rationale: The correct location to auscultate the pulmonary valve is the second intercostal space at the left sternal border. This area is where the pulmonary valve can best be heard due to its anatomical position. Choice B, the fifth intercostal space at the midclavicular line, is the location for auscultating the mitral valve. Choice C, the fourth intercostal space at the left sternal border, is the area for the tricuspid valve. Choice D, the fifth intercostal space at the left anterior axillary line, is the site for listening to the mitral valve as well. Therefore, option A is the correct choice for auscultating the pulmonary valve.
A client with limited mobility in his lower extremities is being cared for by a nurse. Which of the following actions should the nurse take to prevent skin breakdown?
- A. Place the client in high-Fowler's position
- B. Increase the client's intake of carbohydrates
- C. Massage the reddened areas with unscented lotion
- D. Have the client use a trapeze bar when changing positions
Correct Answer: D
Rationale: The correct answer is to have the client use a trapeze bar when changing positions. This action helps in repositioning without causing friction or shearing, which can lead to skin breakdown. Placing the client in high-Fowler's position (Choice A) may not directly prevent skin breakdown related to limited mobility. Increasing carbohydrate intake (Choice B) is not relevant to preventing skin breakdown. Massaging reddened areas with lotion (Choice C) can potentially cause more harm by increasing friction and damaging the skin further, rather than preventing breakdown.