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A nurse is caring for a client who has a full arm cast and reports a pain level of 8 on a scale of 0 to 10, which is unrelieved by pain medication. Which of the following actions should the nurse plan to take first?
- A. Check the circulation of the affected extremity.
- B. Administer additional pain medication.
- C. Reposition the affected extremity.
- D. Document the findings.
Correct Answer: A
Rationale: The correct answer is A: Check the circulation of the affected extremity. This should be the first action because the client's pain is unrelieved by medication, indicating a potential circulation issue that needs immediate attention to prevent complications like compartment syndrome. Checking circulation involves assessing for skin color, temperature, capillary refill, pulse, and sensation. Administering more pain medication (B) without addressing the underlying cause may mask symptoms and delay proper treatment. Repositioning the extremity (C) may worsen the condition if circulation is compromised. Documenting the findings (D) is important but not the priority when the client is experiencing severe unrelieved pain.
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A client diagnosed with diverticulitis has been experiencing episodes of gastrointestinal cramping. The nurse should tell the client to maintain which type of diet during the asymptomatic period?
- A. High in carbohydrates.
- B. High in fiber.
- C. Low in residue.
- D. Low in fat.
Correct Answer: B
Rationale: The correct answer is B: High in fiber. During the asymptomatic period of diverticulitis, a high-fiber diet helps prevent diverticula formation and reduces the risk of diverticulitis flare-ups by promoting regular bowel movements and preventing constipation. Fiber also helps maintain healthy gut flora. Choices A, C, and D are incorrect as high carbohydrates may worsen symptoms, low residue may lead to constipation, and low fat is not directly related to diverticulitis management.
A nurse is preparing to administer ziprasidone 10 mg IM every 6 hr. Available is ziprasidone 20 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
Correct Answer: 0.5
Rationale: The correct answer is 0.5 mL. To calculate this, first determine the total dose needed per administration (10 mg). Then, divide the total dose by the concentration of the medication (20 mg/mL) to find the volume to administer per dose (10 mg ÷ 20 mg/mL = 0.5 mL). This ensures the patient receives the correct amount of medication. Other choices are incorrect because they do not accurately calculate the volume needed for the specified dose. For example, choosing a higher volume would result in overdosing the patient, while choosing a lower volume would underdose the patient. The correct calculation is essential to ensure the patient's safety and therapeutic effectiveness.
A nurse is admitting a client who sustained severe burn injuries. The nurse refers to the burn injury. What percentage of body surface area should the nurse estimate?
- A. 7%
- B. 4%
- C. 1%
- D. 8%
- E. 5%
Correct Answer: D
Rationale: The nurse should estimate the percentage of body surface area affected by the burn injury using the Rule of Nines. According to this rule, specific body areas are assigned percentages: head (9%), each arm (9% total), each leg (18% total), front torso (18%), back torso (18%), and perineum (1%). By adding these percentages, a total of 100% is obtained. For severe burns, the nurse should estimate using the Rule of Nines, making D (8%) the most appropriate choice as it closely aligns with the total percentage of body surface area affected by the burn. Choices A, B, C, and E do not align with the Rule of Nines and would not accurately estimate the extent of the burn injury.
A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse understanding of the procedure?
- A. Soon those shock waves will get rid of my gallstones.
- B. I’ll have a camera put down my throat so they can see my gallbladder.
- C. They are going to use dye to examine my gallbladder and ducts.
- D. They’ll put medication into my gallbladder to dissolve the stones.
Correct Answer: C
Rationale: The correct answer is C because the client's statement indicates an understanding of the procedure. Oral cholangiogram involves injecting dye to visualize the gallbladder and ducts. Choice A is incorrect as shock waves are used in lithotripsy, not oral cholangiogram. Choice B is incorrect as the procedure involves dye, not a camera down the throat. Choice D is incorrect as medication is not used in this procedure.
A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?
- A. I have no appetite.
- B. The pain hurts so much it is making me nauseous.
- C. When I position myself on my right side, it makes the pain worse.
- D. The pain seems to be gone now.
Correct Answer: D
Rationale: The correct answer is D because sudden relief of pain in appendicitis could indicate a ruptured appendix, which is a surgical emergency requiring immediate intervention. This is because when the appendix ruptures, the pain initially decreases due to the release of pressure in the appendix, but the situation can quickly escalate to a life-threatening condition like peritonitis. Choices A, B, and C all indicate ongoing symptoms of appendicitis that would warrant further assessment and intervention.