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A client with a history of chronic pain requests a nonopioid analgesic. The client is alert but has difficulty describing the exact nature and location of the pain to the nurse. What action should the nurse implement next?
- A. Administer the analgesic as requested.
- B. Request a pain assessment from another nurse.
- C. Ask the client to describe the pain more precisely.
- D. Delay administration until the pain is better described.
Correct Answer: D
Rationale: The correct action for the nurse to implement next is to delay administration until the pain is better described. It is essential to have a clear understanding of the nature and location of the pain before administering any analgesic to ensure appropriate and effective pain management. Requesting a pain assessment from another nurse or asking the client to describe the pain more precisely would also be appropriate actions to obtain more information before administering the analgesic. Administering the analgesic as requested without a clear description of the pain may not address the client's needs effectively and could potentially lead to ineffective pain management.
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Which instruction should the nurse provide a client who was recently diagnosed with Raynaud's disease?
- A. Avoid cold temperatures completely.
- B. Take medications only during flare-ups.
- C. Wear gloves when removing packages from the freezer.
- D. Limit physical activity to avoid stress.
Correct Answer: C
Rationale: The correct instruction for a client with Raynaud's disease is to wear gloves when handling cold items to prevent vasospasm. Raynaud's disease is characterized by vasospasm in response to cold or stress, leading to reduced blood flow to extremities. Wearing gloves when removing packages from the freezer helps minimize exposure to cold temperatures and can prevent triggering vasospasms. Choices A, B, and D are incorrect. Avoiding cold temperatures completely is impractical and may not always be possible. Taking medications only during flare-ups does not address prevention strategies, and limiting physical activity to avoid stress is not a primary intervention for Raynaud's disease.
The nurse empties the nasogastric suction collection canister of a client who had a bowel resection the previous day and notes that 1,000 mL of gastric secretions were collected in the last 4 hours. The nurse should assess the client for symptoms of which related problem?
- A. Respiratory acidosis.
- B. Metabolic alkalosis.
- C. Hypoglycemia.
- D. Hyperkalemia.
Correct Answer: B
Rationale: The correct answer is B: Metabolic alkalosis. Loss of gastric secretions can lead to metabolic alkalosis due to the loss of hydrochloric acid. This can result in an increase in blood pH levels. Respiratory acidosis (choice A) is caused by retention of carbon dioxide, not related to the loss of gastric secretions. Hypoglycemia (choice C) is a low blood sugar level and is not directly related to the loss of gastric secretions. Hyperkalemia (choice D) is an elevated potassium level in the blood and is not typically associated with the loss of gastric secretions.
A client reports new onset hearing loss bilaterally after taking a medication with known ototoxic effects. Which type of hearing loss should the nurse suspect?
- A. Conductive
- B. Sensorineural
- C. Mixed
- D. Central
Correct Answer: B
Rationale: The correct answer is B: Sensorineural. Ototoxic medications can lead to sensorineural hearing loss by affecting the inner ear or auditory nerve. Conductive hearing loss is related to issues in the middle or outer ear, not typically caused by ototoxic medications. Mixed hearing loss is a combination of conductive and sensorineural components. Central hearing loss is related to the central nervous system, not commonly caused by ototoxic medications. Therefore, in this case, the nurse should suspect sensorineural hearing loss.
The healthcare provider is assessing a client with a chest tube. Which finding indicates that the chest tube is functioning properly?
- A. Continuous bubbling in the water seal chamber
- B. Tidaling in the water seal chamber
- C. Absence of drainage in the collection chamber
- D. Fluid level in the suction control chamber is below the prescribed level
Correct Answer: B
Rationale: Tidaling in the water seal chamber indicates proper chest tube function. Tidaling refers to the rise and fall of fluid in the water seal with inhalation and exhalation, demonstrating the patency of the system. Continuous bubbling (Choice A) in the water seal chamber indicates an air leak. Absence of drainage in the collection chamber (Choice C) is not a desired finding as it suggests no drainage is occurring. A fluid level below the prescribed level in the suction control chamber (Choice D) may indicate inadequate suction.
A client who is newly diagnosed with emphysema is being prepared for discharge. Which instruction is best for the nurse to provide the client to assist them with dyspnea self-management?
- A. Allow additional time to complete physical activities to reduce oxygen demand.
- B. Practice inhaling through the nose and exhaling slowly through pursed lips.
- C. Use a humidifier to increase home air quality humidity between 30-50%.
- D. Strengthen abdominal muscles by alternating leg raises during exhalation.
Correct Answer: B
Rationale: The correct answer is B. Instructing the client to practice inhaling through the nose and exhaling slowly through pursed lips can help improve oxygenation and reduce dyspnea. This technique, known as pursed lip breathing, can help regulate breathing patterns and decrease the work of breathing in clients with emphysema. Choice A is incorrect because allowing additional time for physical activities does not directly address dyspnea management. Choice C is incorrect as using a humidifier, although beneficial for respiratory conditions, does not specifically assist with dyspnea self-management. Choice D is also incorrect as strengthening abdominal muscles through leg raises does not directly target dyspnea relief.