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A nurse is monitoring a client who is receiving opioid analgesia for adverse effects of the medication. Which of the following effects should the nurse anticipate? Select all.
- A. Urinary incontinence
- B. Diarrhea
- C. Bradypnea
- D. Orthostatic hypotension
- E. Nausea
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. Opioid analgesics can cause respiratory depression (bradypnea), leading to shallow breathing. Orthostatic hypotension is a potential side effect due to vasodilation. Nausea is common with opioid use as they can stimulate the chemoreceptor trigger zone. Urinary incontinence (A) and diarrhea (B) are not typically associated with opioid analgesics. So, the nurse should anticipate monitoring for bradypnea, orthostatic hypotension, and nausea as potential adverse effects.
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A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway?
- A. Encourage isometric exercises
- B. Suction Q8 hr
- C. Give low-dose heparin
- D. Promote incentive spirometer use
Correct Answer: D
Rationale: The correct answer is D: Promote incentive spirometer use. This intervention helps prevent atelectasis, a common complication of prolonged bed rest. Using the incentive spirometer helps the client take deep breaths and improve lung function, thereby maintaining airway patency. Encouraging isometric exercises (choice A) does not specifically target airway patency. Suctioning every 8 hours (choice B) is not necessary unless there is a specific indication. Giving low-dose heparin (choice C) is used to prevent blood clots, not to maintain airway patency.
A nurse observes an AP reprimanding a client for not using the urinal properly. The AP tells him she will put a diaper on him if he does not use the urinal more carefully next time. Which of the following torts is the AP committing?
- A. "Assault"
- B. Battery
- C. False imprisonment
- D. Invasion of privacy
Correct Answer: A
Rationale: The correct answer is A: "Assault." Assault is the intentional act that creates fear of imminent harmful or offensive contact. In this scenario, the AP's threat of putting a diaper on the client if he does not use the urinal properly next time constitutes assault as it instills fear in the client. Choice B, Battery, involves actual harmful or offensive contact, which is not present here. Choice C, False Imprisonment, involves restricting someone's freedom of movement, which is not happening in this scenario. Choice D, Invasion of Privacy, is not applicable as the situation does not involve a violation of the client's privacy.
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
- A. Have the client hold his breath briefly
- B. Discontinue the fluid instillation
- C. Remind the client that cramping is common at this time
- D. Lower the enema fluid container
Correct Answer: D
Rationale: The correct answer is D: Lower the enema fluid container. This intervention helps slow down the flow of the enema solution, reducing the client's discomfort from cramping. By lowering the container, the rate of fluid instillation decreases, giving the client's body more time to adjust to the enema. This action promotes better tolerance and helps alleviate abdominal cramping.
Other choices are incorrect:
A: Having the client hold his breath briefly does not address the underlying cause of the cramping and may increase discomfort.
B: Discontinuing the fluid instillation abruptly can cause incomplete cleansing and may not address the cramping effectively.
C: Merely reminding the client that cramping is common does not provide immediate relief or help manage the discomfort.
By choosing option D, the nurse can effectively manage the client's cramping during the enema procedure.
A nurse educator is reviewing with a newly hired nurse the difference in clinical manifestations of a localized vs. a systemic infection. The nurse indicates understanding when she states that which of the following are clinical manifestations of a systemic infection? Select all.
- A. Fever
- B. Malaise
- C. Edema
- D. Pain or tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A, B, E
Rationale: The correct answer is A, B, E. Fever is a common systemic response to infection as the body raises its temperature to help fight off pathogens. Malaise, a general feeling of discomfort or uneasiness, is also a systemic manifestation indicating a more widespread infection affecting overall well-being. An increase in pulse and respiratory rate can indicate systemic involvement as the body tries to cope with the infection. Edema, pain, or tenderness are more indicative of localized infections and not typically seen in systemic infections.
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. Occupational therapists specialize in helping individuals with physical limitations to maximize their ability to perform daily activities, such as self-feeding. They can assess the client's specific needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Social workers (A) focus more on psychosocial support, certified nursing assistants (B) provide direct care but may not have the expertise in adaptive devices, and registered dietitians (C) focus on nutrition-related issues. Therefore, the occupational therapist (D) is the most appropriate member of the interprofessional care team to address the client's self-feeding difficulties due to rheumatoid arthritis.