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A nurse is assessing a client who is postoperative following an open reduction and internal fixation (ORIF) of the femur. Which of the following assessments should be the nurse's priority?
- A. Braden Scale
- B. Pain assessment
- C. Morse Fall Risk Scale
- D. Nutritional assessment
Correct Answer: B
Rationale: The correct answer is B: Pain assessment. Pain assessment should be the nurse's priority because postoperative pain management is crucial for the client's comfort, recovery, and overall well-being. Uncontrolled pain can lead to complications such as decreased mobility, respiratory issues, and delayed healing. Assessing and managing pain promptly can also prevent potential complications and promote early mobilization. The other choices are not the nurse's priority in this scenario. The Braden Scale assesses the risk of pressure ulcers, Morse Fall Risk Scale assesses the risk of falls, and nutritional assessment is important but not the priority immediately post-ORIF surgery.
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A nurse on an intensive care unit is planning care for a client who has increased intracranial pressure following a head injury. Which of the following IV medications should the nurse plan to administer?
- A. Propranolol
- B. Dobutamine
- C. Mannitol
- D. Chlorpromazine
Correct Answer: C
Rationale: The correct answer is C: Mannitol. Mannitol is an osmotic diuretic that helps reduce cerebral edema by drawing water out of brain tissue. This helps decrease intracranial pressure in clients with head injuries. Propranolol (A) is a beta-blocker used for hypertension, not specifically for intracranial pressure. Dobutamine (B) is a beta-adrenergic agonist used for cardiac support, not for intracranial pressure. Chlorpromazine (D) is an antipsychotic medication and does not address intracranial pressure. In summary, Mannitol is the appropriate choice for managing increased intracranial pressure due to its osmotic diuretic properties.
A nurse is assessing a client who has a urinary catheter. The nurse notes the client's IV tubing is kinked and the urinary catheter bag is lying next to the client in bed. The nurse should identify that the client is at risk for which of the following conditions?
- A. Neurogenic bladder
- B. Infection
- C. Skin breakdown
- D. Pistolate
Correct Answer: B
Rationale: The correct answer is B: Infection. The kinked IV tubing and the urinary catheter bag lying next to the client in bed can lead to contamination of the catheter system, increasing the risk of a urinary tract infection. The kinked tubing can cause backup of urine, leading to bacterial growth, while the catheter bag being on the bed can introduce pathogens to the catheter. Infections can result in serious complications for the client if not addressed promptly. The other choices, A: Neurogenic bladder, C: Skin breakdown, and D: Pistolate, are not directly related to the scenario presented and do not pose an immediate risk based on the information provided.
A nurse is admitting a client who has arthritis pain and reports taking ibuprofen several times daily for 3 years. Which of the following tests should the nurse monitor?
- A. Serum calcium
- B. Stool for occult blood
- C. Fasting blood glucose
- D. Urine for white blood cells
Correct Answer: B
Rationale: The correct answer is B: Stool for occult blood. Long-term use of ibuprofen can lead to gastrointestinal bleeding, which may not always present with visible blood in the stool. Monitoring for occult blood helps detect this potential side effect early. Choices A, C, and D are not directly related to the adverse effects of ibuprofen use. Serum calcium is not typically affected by ibuprofen. Fasting blood glucose monitoring is more relevant for medications affecting glucose metabolism. Urine for white blood cells is not a common test for monitoring the side effects of ibuprofen.
A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?
- A. Abnormal vaginal bleeding
- B. Frequent diarrhea
- C. Urinary hesitancy
- D. Unexplained weight gain
Correct Answer: A
Rationale: The correct answer is A: Abnormal vaginal bleeding. This is a possible indication of cervical cancer because it can be a symptom of cervical dysplasia or cervical cancer. Bleeding between periods, after intercourse, or post-menopausal bleeding may indicate cervical cancer. Frequent diarrhea (B), urinary hesitancy (C), and unexplained weight gain (D) are not typically associated with cervical cancer. Diarrhea and urinary hesitancy are more commonly linked to gastrointestinal or urinary issues, while unexplained weight gain may be indicative of hormonal imbalances or other health conditions unrelated to cervical cancer.
A nurse is providing discharge teaching to a client who reports that they cannot afford their prescribed medication. Which of the following statements should the nurse make?
- A. I can arrange for a social worker to talk with you before you leave.'
- B. I can contact the occupational therapist to schedule a home visit.'
- C. Contact your pharmacy to inquire about a different medication.'
- D. You should ask your provider to prescribe a cheaper medication.'
Correct Answer: A
Rationale: The correct answer is A: "I can arrange for a social worker to talk with you before you leave." This option is the most appropriate as it addresses the client's financial constraints by offering assistance in accessing support services. A social worker can help the client explore options for medication assistance programs, financial aid, or community resources. Option B is incorrect as it does not directly address the client's medication affordability issue. Option C suggests switching medications without considering the client's specific needs. Option D places the burden on the client to navigate the healthcare system for cost-effective solutions. Option A is the best choice as it prioritizes addressing the client's financial barriers through appropriate referral and support.