Nokea
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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Physical examination of a client regarding mobility status should:
- A. begin with gait.
- B. be oriented to time, place, and person.
- C. begin with the Romberg test.
- D. begin with the Tandem Walk test.
Correct Answer: A
Rationale: Gait is usually assessed as the client walks into the room. Normal gait is smooth, flowing, and rhythmic without assistive devices.
The nurse is teaching the client, who is 24 hours post abdominal surgery, how to use an IS. Which instructions should the nurse include in the teaching? Select all that apply.
- A. Inhale slowly and deeply through mouth
- B. Seal lips tightly around mouthpiece
- C. After inhaling, hold breath for 2 to 3 seconds
- D. Sit with the HOB down and bed almost flat
- E. Splint the incision with pillows
- F. Exhale forcefully, fast, and hard
Correct Answer: A,B,C,E
Rationale: A: Deep inhalation maximizes alveolar inflation. B: Sealing prevents air leaks. C: Holding breath enhances lung expansion. E: Splinting reduces pain, aiding inhalation. D: High Fowler's position is optimal. F: Slow exhalation prevents hyperventilation.
At what point in the nurse-client relationship should termination first be addressed?
- A. in the working phase
- B. in the termination phase
- C. in the orientation phase
- D. when the client initially brings up the topic
Correct Answer: C
Rationale: The client has a right to know the parameters of the nurse-client relationship. If the relationship is to be time limited, the client should be informed of the number of sessions. If it is open-ended, the termination date is not known at the outset, and the client should know that this is an issue that is negotiated at a later date.
The client with diarrhea has had four bowel movements in the past eight hours, measuring 150 mL, 100 mL, 100 mL and 150 mL. The client is to receive one-to-one replacement with a bolus of IV 0.9% NaCl to be infused over the next two hours. How many mL of 0.9% NaCl will the nurse infuse each hour?
Correct Answer: 250
Rationale: Total loss is 500 mL (150+100+100+150). One-to-one replacement means 500 mL over 2 hours, so 500/ 2 = 250 mL per hour.
The LPN is auscultating for bowel sounds and hears between 3 and 4 bowel sounds per minute. This is a somewhat expected finding for which of these clients?
- A. a 63-year-old female undergoing chemotherapy for breast cancer
- B. a 56-year-old female with dementia undergoing a swallow study
- C. a 34-year-old male with a PEG tube newly admitted for diabetic ketoacidosis
- D. a 45-year-old male recovering from a knee replacement under general anesthesia
Correct Answer: D
Rationale: When recovering from general anesthesia, hypoactive bowel sounds can be expected. For other clients, less than 5 bowel sounds per minute is an abnormal finding.