Nokea
A nurse is assigned to a client with venous thrombus. The nurse identifies a nursing diagnosis of Impaired physical mobility related to pain. Which should the nurse do first?
- A. Elevate the legs
- B. Elevate the legs by using a pillow under the knees
- C. Encourage adequate fluid intake
- D. Massage the lower legs
Correct Answer: A
Rationale: Elevating the legs (without knee flexion) promotes venous return, reducing pain and swelling in venous thrombus, addressing impaired mobility. Elevating with a pillow under the knees may impede flow, fluids are secondary, and massaging risks dislodging the thrombus.
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A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
Atropine sulfate (Atropine) is contraindicated in all but which one of the following clients?
- A. A client with diabetes.
- B. A client with glaucoma.
- C. A client with urine retention.
- D. A client with bowel obstruction.
Correct Answer: A
Rationale: Atropine is contraindicated in glaucoma (increases intraocular pressure), urine retention (worsens retention), and bowel obstruction (reduces motility). It is not contraindicated in diabetes, as it has no direct effect on glucose metabolism.
What is a priority nursing action for a client post-ileal conduit surgery?
- A. Monitor stoma color.
- B. Administer antibiotics.
- C. Encourage bed rest.
- D. Limit fluid intake.
Correct Answer: A
Rationale: Monitoring stoma color ensures viability; a pink/red stoma indicates good blood supply.
A client comes to the health clinic 3 years after undergoing a resection of the terminal ileum and tells the nurse that he has weakness, shortness of breath, and a sore tongue. Which client statement indicates a need for intervention and client teaching?
- A. I have been drinking plenty of fluids.'
- B. I have been gargling with warm salt water for my sore tongue.'
- C. I have three to four loose stools per day.'
- D. I take a vitamin B12 tablet every day.'
Correct Answer: D
Rationale: Resection of the terminal ileum impairs vitamin B12 absorption, as the ileum is the primary site for B12 uptake. The client's symptoms (weakness, shortness of breath, sore tongue) suggest B12 deficiency, likely due to inadequate absorption of oral B12 supplements. The statement about taking a B12 tablet daily indicates a need for intervention, as the client may require intramuscular B12 injections. The other statements are appropriate or expected (loose stools are common post-resection).
A client with end-stage cancer is receiving morphine for pain. The family is concerned about addiction. The nurse should explain that:
- A. Addiction is not a concern in terminal illness.
- B. Morphine will be tapered to prevent addiction.
- C. Addiction is common but manageable.
- D. Morphine should be avoided to prevent addiction.
Correct Answer: A
Rationale: In terminal illness, addiction is not a concern, as the priority is pain control to ensure comfort, and this explanation reassures the family.