Nokea
A nurse is caring for a client who had abdominal surgery. The client is grimacing and has a respiratory rate of 24/min. Which of the following actions should the nurse take first?
- A. Check the client's current level of pain.
- B. Play music in the client's room as a distraction.
- C. Assist the client to reposition in bed.
- D. Offer the client a cold compress.
Correct Answer: A
Rationale: The correct answer is A, checking the client's current level of pain. This is the priority because the client is grimacing, indicating discomfort. Assessing the pain level is crucial in determining the appropriate intervention. It helps in providing timely pain relief and ensuring the client's well-being. Choices B, C, and D are incorrect because they do not address the immediate need of assessing and managing the client's pain. Playing music, repositioning the client, or offering a cold compress may be helpful interventions, but they should come after evaluating the client's pain level.
You may also like to solve these questions
A nurse is preparing to administer an influenza immunization IM to an infant. Which of the following actions should the nurse include in the plan of care?
- A. Use a ½-Inch needle.
- B. Use a 22-gauge needle.
- C. Use the flushing technique.
- D. Use the deltoid muscle for the injection site.
Correct Answer: A
Rationale: The correct answer is A: Use a ½-Inch needle. For infants, a ½-inch needle is recommended for intramuscular (IM) injections to ensure proper administration of the vaccine into the muscle. Using a shorter needle decreases the risk of reaching the bone or causing tissue damage.
B: Using a 22-gauge needle is not specific to infants and may not be the most appropriate size for their smaller muscles.
C: The flushing technique is not relevant to the administration of the vaccine.
D: The deltoid muscle is not typically used as the injection site for infants; the vastus lateralis muscle is more commonly used due to its larger muscle mass and ease of access.
In summary, using a ½-inch needle is the correct choice for an infant receiving an IM influenza immunization to ensure safe and effective administration.
A nurse is reviewing the medical record of a client who is to start using a scopolamine patch for postoperative nausea and vomiting. Which of the following findings is a contraindication for the client to receive the medication?
- A. Ménière's disease
- B. Increased lacrimation
- C. Narrow-angle glaucoma
- D. Urinary frequency
Correct Answer: C
Rationale: The correct answer is C: Narrow-angle glaucoma. Scopolamine can cause pupillary dilation, leading to an increase in intraocular pressure, which can worsen narrow-angle glaucoma. This can potentially result in a sudden increase in pressure within the eye, leading to severe pain, vision changes, and even blindness. Therefore, it is crucial to avoid giving scopolamine to clients with narrow-angle glaucoma to prevent these serious complications.
Choice A: Ménière's disease is not a contraindication for scopolamine patch use.
Choice B: Increased lacrimation is not a contraindication for scopolamine patch use.
Choice D: Urinary frequency is not a contraindication for scopolamine patch use.
A nurse is caring for a client who has Graves' disease and is to start therapy with propylthiouracil. The nurse should expect which of the following outcomes?
- A. Decreased heart rate
- B. Decreased WBC count
- C. Increased Hgb
- D. Increased blood pressure
Correct Answer: A
Rationale: The correct answer is A: Decreased heart rate. Propylthiouracil is an antithyroid medication used to treat hyperthyroidism in conditions like Graves' disease. It works by inhibiting the production of thyroid hormones. Since hyperthyroidism can cause an increased heart rate due to the excess thyroid hormones, the expected outcome of propylthiouracil therapy is a decreased heart rate as it helps normalize thyroid hormone levels. The other choices are incorrect because propylthiouracil does not directly affect WBC count (B), Hgb levels (C), or blood pressure (D) in the context of treating hyperthyroidism.
A nurse is preparing to administer acetaminophen 650 mg rectally. Which of the following actions should the nurse take?
- A. Insert the suppository 5 cm (2 in) into the client's rectum.
- B. Lubricate the flat end of the suppository prior to administration.
- C. Have the client lie on his left side for 5 min after insertion.
- D. Hold the suppository for 1 min to warm it prior to insertion.
Correct Answer: C
Rationale: The correct answer is C: Have the client lie on his left side for 5 min after insertion. This position promotes optimal absorption of the medication. When the client lies on the left side, gravity helps keep the suppository in place and allows it to dissolve and be absorbed more effectively through the rectal mucosa. This position also helps prevent the suppository from being expelled prematurely.
Choice A is incorrect because inserting the suppository 5 cm (2 in) is not necessary for proper administration. Choice B is incorrect as lubricating the suppository is not essential for rectal administration. Choice D is incorrect because warming the suppository is not required and may not be safe. Choices E, F, and G are not provided, so they are not applicable in this scenario.
A nurse is reinforcing teaching with a young adult client who has a new prescription for ear drops. Which of the following instructions should the nurse include?
- A. Chill the medication prior to instillation.
- B. Press a cotton ball firmly in ear canal after administering drops.
- C. Pull the pinna up and back to administer medication.
- D. Place an applicator into the ear canal to instill drops.
Correct Answer: C
Rationale: The correct answer is C: Pull the pinna up and back to administer medication. This instruction is correct because pulling the pinna up and back helps straighten the ear canal in adults, allowing the drops to be instilled properly. This technique ensures that the medication reaches the desired target area for optimal effectiveness.
Explanation of other choices:
A: Chilling the medication is not necessary and can cause discomfort to the client.
B: Pressing a cotton ball firmly in the ear canal can prevent the drops from reaching the ear canal.
D: Placing an applicator into the ear canal can cause injury or damage to the ear canal and eardrum.