A nurse is caring for a client who reports a decrease in the effectiveness of their pain medication. What factor should the nurse identify as contributing to this decrease?
- A. History of frequent alcohol use
- B. Decreased physical activity
- C. Bowel inflammation
- D. History of opioid use
Correct Answer: C
Rationale: The correct answer is C: Bowel inflammation. Bowel inflammation can interfere with the absorption of medications, including pain medication, leading to decreased effectiveness. Choices A, B, and D are incorrect because although they can impact pain management in various ways, they are not directly related to the decreased effectiveness of pain medication due to absorption issues.
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A nurse is assessing a client who reports pain and redness at the site of a peripheral IV. What should the nurse do first?
- A. Apply a cold compress to the site
- B. Discontinue the IV line
- C. Notify the provider
- D. Increase the IV flow rate
Correct Answer: B
Rationale: When a client reports pain and redness at the site of a peripheral IV, indicating signs of phlebitis, the nurse's initial action should be to discontinue the IV line. This helps prevent further complications and ensures patient safety. Applying a cold compress (Choice A) may provide temporary relief but does not address the underlying issue. Notifying the provider (Choice C) is important but not the initial step. Increasing the IV flow rate (Choice D) can exacerbate the inflammation and should be avoided.
A nurse is providing discharge teaching for a client with a prescription for home oxygen therapy. Which instruction should the nurse include?
- A. Increase the oxygen flow rate when shortness of breath occurs
- B. Keep oxygen tubing away from heat sources
- C. Wear synthetic fabrics to prevent static
- D. Turn off the oxygen when not in use
Correct Answer: B
Rationale: The correct instruction for a client with home oxygen therapy is to keep oxygen tubing away from heat sources to prevent fires and other hazards. Option A is incorrect because adjusting the oxygen flow rate without healthcare provider guidance can be dangerous. Option C is incorrect as synthetic fabrics can generate static electricity, which is a fire hazard. Option D is incorrect as oxygen should be left on as prescribed unless advised otherwise.
A nurse is reviewing the lab report of a client who has been experiencing a fever for the last 3 days. What lab result indicates the client is experiencing fluid volume deficit (FVD)?
- A. Decreased BUN levels
- B. Increased hematocrit
- C. Increased white blood cell count
- D. Decreased hematocrit
Correct Answer: B
Rationale: The correct answer is B: Increased hematocrit. Increased hematocrit indicates hemoconcentration, which is a sign of fluid volume deficit. When there is a decrease in fluid volume in the body, the blood becomes more concentrated, leading to an increase in hematocrit levels. Choices A, C, and D are incorrect because decreased BUN levels, increased white blood cell count, and decreased hematocrit are not indicative of fluid volume deficit.
A nurse is preparing to perform an abdominal assessment on a client. Which action should the nurse take first?
- A. Percuss the abdomen
- B. Inspect the abdomen
- C. Auscultate before palpation
- D. Palpate the abdomen
Correct Answer: C
Rationale: The correct answer is to auscultate before palpation. This ensures that bowel sounds are not altered by physical manipulation. Inspecting the abdomen is a valid step but not the first. Percussing and palpating should come after auscultation to prevent altering bowel sounds or causing discomfort to the client.
A nurse is reviewing a client's health history and identifies urinary incontinence as a risk factor for pressure injuries. What should the nurse include in the plan of care?
- A. Use a heating pad for comfort
- B. Apply a barrier cream to the skin
- C. Reposition the client every 4 hours
- D. Change the client's position every 2 hours
Correct Answer: C
Rationale: The correct answer is to reposition the client every 4 hours. Repositioning the client helps prevent pressure injuries caused by urinary incontinence by relieving pressure on vulnerable areas of the skin. Choice A, using a heating pad for comfort, is not directly related to preventing pressure injuries. Choice B, applying a barrier cream to the skin, may help protect the skin but does not address the underlying cause of pressure injuries. Choice D, changing the client's position every 2 hours, is more frequent than necessary and may not be as effective in preventing pressure injuries as repositioning every 4 hours.
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