Nokea
A client with a history of peptic ulcer disease reports epigastric pain. Which action should the nurse take first?
- A. Administer an antacid.
- B. Notify the physician.
- C. Offer a light snack.
- D. Assess the pain characteristics.
Correct Answer: D
Rationale: Assessing pain characteristics provides data to determine the cause and severity, guiding further interventions.
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Select the arterial blood gas that you would report to the client's physician because it is not within normal parameters and it is also a significant change for the client.
- A. PaO2: 65 mm Hg
- B. PaCO2: 40 mm Hg
- C. Arterial blood pH: 7.39
- D. SaO2: 96%
Correct Answer: A
Rationale: PaO2 of 65 mm Hg is below the normal range (75-100 mm Hg), indicating hypoxemia, which requires reporting.
The nurse applies warm compresses to a client's leg. To determine effectiveness of the compresses, the nurse should determine if there is:
- A. Less scaling on the skin.
- B. Decreased bruising.
- C. Improved circulation to the area.
- D. Decreased swelling in the area.
Correct Answer: C
Rationale: Warm compresses promote vasodilation, improving circulation to the area, which aids healing and reduces symptoms.
The nurse is caring for a client with a history of osteoarthritis. Which of the following non-pharmacologic interventions should be included in the plan of care?
- A. Apply heat to affected joints.
- B. Restrict weight-bearing activities.
- C. Encourage a low-protein diet.
- D. Limit range-of-motion exercises.
Correct Answer: A
Rationale: Heat therapy reduces stiffness and pain in osteoarthritis.
A client with a history of schizophrenia is admitted with auditory hallucinations. The nurse should prioritize which of the following interventions?
- A. Provide a quiet environment.
- B. Administer haloperidol as prescribed.
- C. Encourage group therapy immediately.
- D. Restrict the client to their room.
Correct Answer: A, B
Rationale: A quiet environment and haloperidol reduce stimulation and manage hallucinations.
A client with a history of breast cancer is prescribed anastrozole (Arimidex). The nurse should monitor the client for which of the following adverse effects?
- A. Bone loss.
- B. Hyperglycemia.
- C. Hypertension.
- D. Weight gain.
Correct Answer: A
Rationale: Anastrozole, an aromatase inhibitor, can cause bone loss, increasing osteoporosis risk.