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A client with metastatic cancer reports a pain level of 10 on a pain scale of 0 to 10. Twenty minutes after the nurse administers an IV analgesic, the client reports no pain relief. Which intervention is most important for the nurse to include in this client's plan of care?
- A. Administer analgesics on a fixed and continuous schedule.
- B. Frequently evaluate the client's pain.
- C. Replace transdermal analgesic patches every 72 hours.
- D. Monitor client for break-through pain.
Correct Answer: A
Rationale: A fixed and continuous analgesic schedule ensures consistent pain relief for chronic severe cancer pain, preventing fluctuations and addressing inadequate response to the initial dose.
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To reduce the risk for pulmonary complications for a client with Amyotrophic Lateral Sclerosis (ALS), which interventions should the nurse implement? (Select all that apply)
- A. Teach the client breathing exercises.
- B. Establish a regular bladder routine.
- C. Perform chest physiotherapy.
- D. Encourage use of incentive spirometer.
- E. Initiate passive range of motion exercises.
Correct Answer: A,C,D,E
Rationale: Breathing exercises, chest physiotherapy, incentive spirometer use, and passive range of motion exercises directly address respiratory function and mobility, reducing the risk of pulmonary complications in ALS by improving lung expansion, mobilizing secretions, and maintaining joint mobility.
While completing a health assessment for a young adult female with acute appendicitis, the client informs the nurse that there is a chance that she may be pregnant. The operating team is preparing to take the client to surgery. Which intervention should the nurse implement immediately?
- A. Calculate gestation from last menstrual cycle.
- B. Continue with surgery as scheduled.
- C. Perform a bedside pregnancy test.
- D. Notify the surgical team to cancel the surgery.
Correct Answer: C
Rationale: Performing a bedside pregnancy test immediately confirms or rules out pregnancy, ensuring safe surgical planning, as abdominal surgery poses risks to a fetus.
An adult client, a smoker, has had chronic obstructive pulmonary disease (COPD) for twelve years. When conducting discharge teaching, what should the nurse advise the client to avoid in order to prevent exacerbation of COPD?
- A. Exposure to persons with pneumonia or chickenpox.
- B. Excessive physical exertion and respiratory tract infections.
- C. Overdose of albuterol and alcohol consumption.
- D. Excessive bedrest and lack of exercise.
Correct Answer: B
Rationale: Excessive physical exertion and respiratory infections are primary triggers for COPD exacerbation, increasing oxygen demand and causing airway inflammation, which the client should avoid.
After teaching a client newly diagnosed with cholecystitis about recommended diet changes, the nurse evaluates the client's learning. Which food choices eliminated by the client indicate to the nurse that teaching has been successful?
- A. Whole milk and daily servings of ice cream.
- B. Citrus fruit and melon with a salt substitute.
- C. Pasta with herbal butter and no meat sauce.
- D. Canned vegetables with additional table salt.
Correct Answer: A
Rationale: Avoiding high-fat foods like whole milk and ice cream prevents exacerbation of cholecystitis, demonstrating effective understanding of dietary restrictions.
The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
- A. Apical heart rate of 100 to 110 beats/minute.
- B. Redness and edema noted at the incision site.
- C. High-pitched sound heard upon inspiration.
- D. Pain rating of 8 on a scale of 1 to 10.
Correct Answer: C
Rationale: A high-pitched sound (stridor) indicates potential airway obstruction, a life-threatening emergency requiring immediate intervention to ensure airway patency.