Nokea
A client with pancreatic cancer is receiving morphine via a subcutaneous pump. The client is developing drug tolerance. The nurse understands that the client is:
- A. Tolerating the medication well.
- B. Showing addiction to morphine.
- C. Requiring an increased dose.
- D. Experiencing physical dependence.
Correct Answer: C
Rationale: Drug tolerance means the client requires an increased dose to achieve the same pain relief, as the body has adapted to the current dose of morphine.
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Blood pressure in the systemic circulation is highest in the:
- A. Arterioles
- B. Capillaries
- C. Aorta
- D. Venules
Correct Answer: C
Rationale: Blood pressure is highest in the aorta, where blood is ejected directly from the left ventricle during systole, generating peak pressure (systolic pressure). As blood flows through arterioles, capillaries, and venules, pressure progressively decreases due to resistance and vessel compliance. This makes the aorta the correct answer.
A client post-cystoscopy reports severe pain. The nurse should:
- A. Administer analgesics as prescribed.
- B. Encourage ambulation.
- C. Apply a cold pack.
- D. Notify the physician.
Correct Answer: D
Rationale: Severe pain post-cystoscopy is abnormal and requires physician notification to rule out complications.
A client with acute renal failure has an increase in the serum potassium level. The nurse should monitor the client for:
- A. Cardiac arrest.
- B. Pulmonary edema.
- C. Circulatory collapse.
- D. Hemorrhage.
Correct Answer: A
Rationale: Elevated potassium can cause cardiac arrhythmias, potentially leading to cardiac arrest, requiring close monitoring.
A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?
- A. Cyanosis.
- B. Flushed skin.
- C. Irritability.
- D. Anxiety.
Correct Answer: C
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.
The nurse has assisted the physician at the bedside with insertion of a left subclavian, triple lumen catheter in a client admitted with lung cancer. Suddenly, the client becomes restless and tachypneic. The nurse should:
- A. Assess breath sounds.
- B. Remove the catheter.
- C. Insert a peripheral I.V.
- D. Reposition the client.
Correct Answer: A
Rationale: Restlessness and tachypnea post-catheter insertion suggest a pneumothorax, a complication. Assessing breath sounds detects absent or diminished sounds, guiding intervention. Removing the catheter, inserting an I.V., or repositioning does not address the urgent issue.