Nokea
A client with cancer pain is prescribed oxycodone. Which information is most essential to reinforce in order to help prevent long-term complications?
- A. How to monitor blood pressure daily
- B. How to prevent constipation
- C. How to prevent itching
- D. How to prevent nausea
Correct Answer: B
Rationale: Constipation is a common, long-term complication of oxycodone, requiring preventive measures like fiber and fluids. Blood pressure monitoring, itching, and nausea are less critical long-term concerns.
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Laboratory reference ranges
INR
0.8-1.1
The nurse receives report on 4 clients. Which of the following clients should the nurse see first?
- A. Client receiving IV vancomycin who reports discomfort at the peripheral IV site
- B. Client with a pulmonary embolus receiving continuous IV heparin infusion and warfarin who has an INR of 1.9
- C. Client 1 day postoperative receiving patient-controlled analgesia with morphine who reports itching and nausea
- D. Client receiving maintenance IV 0.9% sodium chloride with labeled tubing indicating that tubing was changed 48 hours ago
Correct Answer: A
Rationale: Discomfort at an IV vancomycin site suggests possible infiltration or phlebitis, requiring immediate assessment to prevent tissue damage. INR of 1.9 is subtherapeutic but less urgent, itching/nausea are expected morphine side effects, and tubing changed 48 hours ago is within standard protocol.
A client with aortic stenosis is scheduled for surgery in 2 weeks. The client reports episodes of angina and passing out twice at home. Which would be the best response by the nurse to explain the appropriate activity for this client at this time?
- A. Avoid strenuous activity before the surgery
- B. Continue to exercise, even if angina occurs. It will strengthen your heart muscles
- C. Take short walks 3 times a day
- D. There are no activity restrictions unless angina occurs
Correct Answer: A
Rationale: Strenuous activity risks syncope or ischemia in aortic stenosis, so avoidance is critical. Exercise despite angina is dangerous, short walks may still trigger symptoms, and no restrictions ignore risks.
The nurse is caring for a 2-year-old who had an anaphylactic reaction to a bee sting. After the nurse reinforces teaching on applying epinephrine, which statements by the parent indicate correct understanding? Select all that apply.
- A. I will give the injection if my child has trouble breathing after a bee sting
- B. I will give the injection in the upper arm
- C. I will keep an epinephrine injection close to my child at all times
- D. I will take my child to the emergency room after giving the injection
- E. The injection can be given through clothing
Correct Answer: A,C,D,E
Rationale: Epinephrine is given for breathing difficulty, kept accessible, followed by ER visit, and can be administered through clothing. The correct site is the thigh, not the upper arm, making B incorrect.
The LPN is caring for all of the following women on the postpartum unit. Which situation requires further attention?
- A. A woman who gave birth four hours ago has red vaginal drainage on her perineal pad.
- B. The nurse palpates the uterine fundus 3 cm above the umbilicus in a woman who gave birth 12 hours ago.
- C. A woman who had a 20-hour labor and gave birth 8 hours ago asks the nurse not to bring her baby in for breastfeeding during the night.
- D. A woman who gave birth yesterday is sweating profusely and producing large amounts of urine.
Correct Answer: B
Rationale: A fundus 3 cm above the umbilicus 12 hours postpartum suggests uterine atony or retained clots, requiring further assessment to prevent hemorrhage. Other findings are normal or less urgent.
The nurse is caring for a client who had a total abdominal hysterectomy 2 days ago. The client reports hearing music coming from the television, which is turned off. Which of the following actions should the nurse take first?
- A. Ask the client when the auditory hallucinations began
- B. Check the client’s medication administration record
- C. Obtain a set of vital signs including temperature
- D. Turn on the television to see if the music stops
Correct Answer: B
Rationale: Checking the medication record identifies potential causes of hallucinations, such as opioids or anesthetics. Timing, vital signs, and TV checks are secondary to ruling out medication effects.