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A client with acute appendicitis develops a fever, tachycardia, and hypotension. Based on these assessment findings, the nurse should further assess the client for which of the following complications?
- A. Deficient fluid volume.
- B. Intestinal obstruction.
- C. Bowel ischemia.
- D. Peritonitis.
Correct Answer: D
Rationale: Fever, tachycardia, and hypotension in acute appendicitis suggest peritonitis, a complication from possible appendiceal rupture. Deficient fluid volume, obstruction, or ischemia are less directly indicated by these signs. CN: Physiological adaptation; CL: Analyze
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The nurse is caring for a client with a femoral fracture in traction. Which observation indicates a potential complication?
- A. Client reports mild discomfort.
- B. Traction ropes are aligned with the pulley.
- C. Foot is pale and cool to touch.
- D. Pin sites are clean and dry.
Correct Answer: C
Rationale: A pale, cool foot suggests impaired circulation, a serious complication requiring immediate attention.
Following a thoracotomy, the client has severe pain. Which of the following strategies for pain management will be most effective for this client?
- A. Repositioning the client immediately after administering pain medication.
- B. Reassessing the client 30 minutes after administering pain medication.
- C. Verbally reassuring the client after administering pain medication.
- D. Readjusting the pain medication dosage as needed according to the client's condition.
Correct Answer: D
Rationale: Readjusting pain medication dosage based on the client's condition ensures adequate pain control, critical for recovery. Repositioning, reassessing, and reassurance are supportive but less effective alone.
Which of the following medications should be available to provide emergency treatment if a client develops tetany after a subtotal thyroidectomy?
- A. Sodium phosphate.
- B. Calcium gluconate.
- C. Echothiophate iodide.
- D. Sodium bicarbonate.
Correct Answer: B
Rationale: Calcium gluconate is used to treat tetany by correcting hypocalcemia, which causes muscle spasms and tingling.
The nurse should teach the client who is receiving warfarin sodium that:
- A. Partial thromboplastin time values determine the dosage of warfarin sodium.
- B. Protamine sulfate is used to reverse the effects of warfarin sodium.
- C. International Normalized Ratio (INR) is used to assess effectiveness.
- D. Warfarin sodium will facilitate clotting of the blood.
Correct Answer: C
Rationale: INR monitors warfarin's anticoagulant effectiveness, guiding dosage adjustments to prevent clotting or bleeding.
A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used?
- A. The client exhibits intolerance to many drugs.
- B. The client experiences spontaneous remissions from time to time.
- C. The client requires multiple drugs simultaneously.
- D. The client endures long periods of exacerbation before the illness responds to a particular drug.
Correct Answer: B
Rationale: Spontaneous remissions in MS make it challenging to attribute symptom improvement to drugs versus natural disease course. Intolerance, multiple drugs, or delayed responses are less primary factors.