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A client's postoperative pain seems to be getting worse instead of better. When the nurse asks the client, 'Why do you think it's getting worse?' the client replies, 'My wife died last month. It's all I can think about.' The nurse must now consider:
- A. calling the physician for an increased dosage of pain medication
- B. calling the physician for a sedative
- C. referring the client for a psychiatric consult
- D. developing interventions for grief and loss
Correct Answer: D
Rationale: The client's grief over his wife's death is likely exacerbating his pain perception, requiring grief and loss interventions to address the affective component.
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The nurse is inserting a urinary catheter in the client with urinary retention. During balloon inflation, the client reports pain. What is the nurse's best action?
- A. Withdraw the sterile water from the balloon and advance the catheter further.
- B. Continue inflating the balloon as this finding is expected during catheter insertion.
- C. Remove the catheter and reattempt insertion with a smaller urinary catheter.
- D. Reposition the catheter by rotating it slightly and continue to inflate the balloon.
Correct Answer: A
Rationale: A: Pain suggests the catheter is in the urethra, not the bladder; advancing after deflating corrects placement. B: Pain is abnormal and risks damage. C: Removal is unnecessary if advancement works. D: Rotating a partially inflated balloon could harm the urethra.
A 15 year-old high school wrestler has been taking diuretics to lose weight to compete in a lower weight class. Which of the following medical tests is most likely to be given?
- A. Lab values of Potassium and Sodium
- B. Lab values of glucose and hemoglobin
- C. ECG
- D. CT scan
Correct Answer: A
Rationale: Diuretics can disturb the sodium and potassium balance, resulting in cardiac complications. Monitoring electrolyte levels is critical.
People who live in poverty are most likely to obtain health care from:
- A. their primary care physician (family doctor)
- B. a neighborhood clinic
- C. specialists
- D. Emergency Departments or urgent care centers
Correct Answer: D
Rationale: Economic barriers often lead those in poverty to seek care from Emergency Departments or urgent care centers, which are more accessible than primary care or specialists.
The LPN is preparing to clean a client's PEG tube. Which of the following tasks should the nurse perform? A. Gently remove crusty drainage from the site. B. Pull the tube in multiple directions to ensure it is secure. C. Thoroughly dry the skin around the tube site with a clean towel. D. Use mild soap to clean around the tube site. E. Apply talcum powder to the tube site.
- A. B, D, E
- B. A, B, C
- C. A, C, D
- D. C, D, E
Correct Answer: C
Rationale: LPNs caring for the PEG tube should be careful to not disrupt the tube, pull on the tube, or apply any ointment or powder near or on the tube. Talcum powder may irritate the stoma.
The nurse is assessing the female client who is 65 inches tall and has a small body frame. Based on the information in the chart illustrated, what is the client's approximate ideal body weight?
Correct Answer: 117
Rationale: Height is 5'5†(65/ 12 = 5 remainder 5). Formula: 105 lb for 5 ft + 5 lb × 5 = 130 lb. Small frame subtracts 10% (130 × 0.1 = 13 lb). 130 − 13 = 117 lb.