Nokea
A nurse is caring for a client who is 1 day postoperative following a total knee replacement. The client reports pain of 8 on a scale of 0 to 10. Which of the following actions should the nurse take?
- A. Administer ibuprofen 400 mg PO
- B. Administer oxycodone 10 mg PO
- C. Reposition the client to the unaffected side
- D. Apply a cold compress to the affected knee
Correct Answer: B
Rationale: In this scenario, the appropriate action for the nurse to take when a client reports severe postoperative pain of 8 out of 10 is to administer oxycodone 10 mg PO. Oxycodone is a potent analgesic that is more effective in managing severe pain compared to ibuprofen, making choice A incorrect. Repositioning the client to the unaffected side or applying a cold compress may provide some comfort but are not the priority interventions for severe postoperative pain, making choices C and D less appropriate.
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A client has had vomiting and diarrhea for the past 3 days. Which of the following findings indicates the client is experiencing fluid volume deficit?
- A. Jugular vein distention
- B. Bradycardia
- C. Increased respiratory rate
- D. Bounding pulses
Correct Answer: C
Rationale: An increased respiratory rate is a sign of fluid volume deficit as the body attempts to compensate for decreased blood volume. Jugular vein distention, bradycardia, and bounding pulses are not typical findings of fluid volume deficit. Jugular vein distention is more commonly associated with fluid volume overload, bradycardia can be a sign of fluid volume excess or other issues, and bounding pulses are not typically seen in fluid volume deficit.
A nurse is assessing a client who is in active labor. Which of the following findings should the nurse report to the provider?
- A. Contractions lasting 80 seconds.
- B. FHR baseline 170/min.
- C. Early decelerations in the FHR.
- D. Temperature 37.4°C (99.3°F).
Correct Answer: B
Rationale: The correct answer is B. An FHR baseline of 170/min is considered tachycardia, which is above the normal range during labor and requires immediate attention. High FHR can indicate fetal distress or maternal fever. Choice A, contractions lasting 80 seconds, are within normal range for active labor. Choice C, early decelerations in the FHR, are usually benign and do not typically require immediate intervention. Choice D, a temperature of 37.4°C (99.3°F), is within normal limits.
A nurse is reviewing the medical record of a client who has a prescription for spironolactone. Which of the following findings should the nurse report to the provider?
- A. Potassium 5.0 mEq/L
- B. Blood pressure 136/84 mm Hg
- C. Sodium 140 mEq/L
- D. Calcium 9.5 mg/dL
Correct Answer: A
Rationale: A potassium level of 5.0 mEq/L is at the upper limit of normal and should be monitored closely in clients taking spironolactone, which is potassium-sparing. Elevated potassium levels can lead to hyperkalemia, especially in individuals on potassium-sparing diuretics like spironolactone. Monitoring and reporting high potassium levels are crucial to prevent potential complications such as cardiac arrhythmias. Blood pressure (choice B), sodium level (choice C), and calcium level (choice D) are not directly related to the use of spironolactone and do not require immediate reporting in this scenario.
A healthcare provider is preparing education material for a client. Which technique should the healthcare provider use in creating the material?
- A. Emphasize important information using bold lettering.
- B. Use a 7th-grade reading level.
- C. Avoid using cartoons in the material.
- D. Use words with three or four syllables.
Correct Answer: B
Rationale: Using a 7th-grade reading level is the most effective technique when creating education material for clients because it ensures that the content is easily understood by a wide range of individuals. Option A, emphasizing important information with bold lettering, may help draw attention but doesn't guarantee comprehension. Option C, avoiding cartoons, is not necessarily a universal rule and can sometimes make material more engaging. Option D, using words with three or four syllables, can make the material more complex and harder to understand, defeating the purpose of effective communication in education material.
A nurse is caring for a client who is in labor and requires augmentation of labor. Which of the following conditions should the nurse recognize as a contraindication to the use of oxytocin?
- A. Diabetes mellitus
- B. Shoulder presentation
- C. Postterm with oligohydramnios
- D. Chorioamnionitis
Correct Answer: B
Rationale: Shoulder presentation is a contraindication for oxytocin because it can increase the risk of complications during labor, such as shoulder dystocia. Diabetes mellitus (Choice A) is not a contraindication for the use of oxytocin. Postterm with oligohydramnios (Choice C) and chorioamnionitis (Choice D) may actually necessitate the use of oxytocin to induce or augment labor for the well-being of the mother and baby.