Nokea
A client with a spinal fusion is using a transcutaneous electrical nerve stimulation (TENS) unit for pain relief. Which client statement indicates correct use?
- A. I'll place the electrodes directly over the incision.'
- B. I'll adjust the intensity to a comfortable level.'
- C. I'll use the unit for 12 hours continuously.'
- D. I'll apply the unit to my lower legs.'
Correct Answer: B
Rationale: Adjusting the TENS unit to a comfortable intensity ensures effective and safe pain relief.
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What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.
Which of the following should the nurse provide as part of the information to prepare the client for tonometry?
- A. Oral pain medication will be given before the procedure.
- B. It is a painless procedure with no adverse effects.
- C. Blurred or double vision may occur after the procedure.
- D. Medication will be given to dilate the pupils before the procedure.
Correct Answer: B
Rationale: Tonometry measures intraocular pressure and is typically painless with no adverse effects, requiring no pupil dilation or pain medication.
The nurse has an order to administer sulfasalazine (Azulfidine) 2 g. The medication is available in 500-mg tablets. How many tablets should the nurse administer?
- A. 2 tablets.
- B. 3 tablets.
- C. 4 tablets.
- D. 5 tablets.
Correct Answer: C
Rationale: To administer 2 g (2000 mg) of sulfasalazine with 500-mg tablets, divide 2000 by 500, which equals 4 tablets. CN: Pharmacological and parenteral therapies; CL: Apply
After surgery for head and neck cancer, a client has a permanent tracheostomy. The nurse should teach the client and family about the importance of:
- A. Providing tracheostomy site care.
- B. Addressing the psychosocial issues related to tracheostomy.
- C. Observing for early signs and symptoms of skin breakdown around the tracheostomy site.
- D. Using humidifiers to prevent thick, tenacious secretions.
Correct Answer: A,C,D
Rationale: Tracheostomy site care (A), monitoring for skin breakdown (C), and using humidifiers (D) are critical to prevent infection, maintain skin integrity, and keep secretions manageable.
A client with pneumonia has a temperature of 102.6°F (39.2°C), is diaphoretic, and has a productive cough. The nurse should include which of the following measures in the plan of care?
- A. Position changes every 4 hours.
- B. Nasotracheal suctioning to clear secretions.
- C. Frequent linen changes.
- D. Frequent offering of a bedpan.
Correct Answer: C
Rationale: Diaphoresis from fever causes damp linens, which can lead to discomfort and skin breakdown; frequent linen changes are needed. Position changes aid lung expansion but are less urgent. Suctioning is invasive and not routinely required. Bedpan use depends on mobility, not fever.