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A client with cholecystitis continues to have severe right upper quadrant pain. The nurse obtains the following vital signs: temperature 38.4°C; pulse 114; respirations 22; blood pressure 142/90. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse recommends to the primary care provider for the client to receive:
- A. Hydromorphone (Dilaudid) I.V.
- B. Diltiazem (Cardizem) PO.
- C. Meperidine (Demerol) I.M.
- D. Promethazine (Phenergan).
Correct Answer: A
Rationale: Severe pain requires a potent analgesic. Hydromorphone I.V. (A) provides rapid, effective pain relief. Diltiazem (B) is for cardiac conditions, not pain. Meperidine (C) is less preferred due to side effects, and promethazine (D) is for nausea, not pain.
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Which of the following instructions should the nurse include in the teaching plan for a client who is experiencing gastroesophageal reflux disease (GERD)?
- A. Limit caffeine intake to two cups of coffee per day.
- B. Do not lie down for 2 hours after eating.
- C. Follow a low-protein diet.
- D. Take medications with milk to decrease irritation.
Correct Answer: B
Rationale: Avoiding lying down for 2 hours after eating prevents reflux of stomach contents into the esophagus, a key strategy for managing GERD. The other options are incorrect or exacerbate symptoms.
A client post-ureteroscopy reports burning on urination. The nurse should:
- A. Encourage fluids.
- B. Administer antibiotics.
- C. Apply a heating pad.
- D. Notify the physician.
Correct Answer: A
Rationale: Burning is common post-ureteroscopy; fluids dilute urine, reducing irritation.
The nurse is planning care for a client with osteomyelitis. The client is taking an antibiotic, but the infection has not resolved. The nurse should advise the client to do which of the following?
- A. Use herbal supplements.
- B. Eat a diet high in protein and vitamins C and D.
- C. Ask the health care provider for a change of antibiotics.
- D. Encourage frequent passive range-of-motion to the affected extremity.
Correct Answer: B
Rationale: A diet high in protein and vitamins C and D supports tissue healing and immune function in osteomyelitis.
A client who has undergone a mastectomy is worried about her body image and its impact on her sexual relationship. The nurse should suggest:
- A. Wearing a prosthesis during intimate moments.
- B. Avoiding discussions about her surgery with her partner.
- C. Focusing only on non-physical aspects of intimacy.
- D. Ignoring her concerns as they are temporary.
Correct Answer: A
Rationale: Wearing a prosthesis can help the client feel more confident about her body image during intimate moments, supporting her sexual relationship.
Which outcome is appropriate for a client with a traumatic brain injury?
- A. Complete memory recovery.
- B. Active participation in therapy.
- C. Return to pre-injury job.
- D. Eliminate all symptoms.
Correct Answer: B
Rationale: Active participation in therapy is a realistic outcome for recovery in traumatic brain injury.