Nokea
A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr
- D. Apply a warm compress to the operative site every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial for the comfort and well-being of the child. Scheduled analgesics help maintain a consistent level of pain relief, preventing peaks and valleys in pain intensity. This approach is especially important in the initial 24 hours following surgery when pain is typically more intense. Offering small amounts of clear liquids 6 hours post-surgery (Choice A) may not be appropriate as the child may still be recovering from anesthesia and at risk of nausea or vomiting. Giving cromolyn nebulized solution every 8 hours (Choice C) is not indicated for postoperative pain management. Applying a warm compress to the operative site every 4 hours (Choice D) may provide some comfort but does not address the underlying need for analgesia.
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Which of the following clients should the nurse instruct the AP to report to the nurse?
- A. A client who has a prescription for compression stockings and did not receive them.
- B. A client who requests assistance in ambulating to the restroom.
- C. A client who ate 50% of their lunch tray.
- D. A client whose blood pressure is 88/52 mmHg.
Correct Answer: D
Rationale: The correct answer is D. A blood pressure of 88/52 mmHg is considered hypotensive and requires immediate attention. The nurse should instruct the AP to report this vital sign reading to the nurse for further assessment and intervention to prevent complications such as hypoperfusion to vital organs. Choices A, B, and C do not pose immediate life-threatening risks and can be addressed during routine care. Choice D stands out as the priority due to the potential for serious consequences if not addressed promptly.
Which of the following actions should the nurse take to reduce the risk for client injury?
- A. Keep the television on during the night
- B. Place the bedside table at the foot of the bed
- C. Raise the side rails up when the client is in bed
- D. Assist the client to the toilet frequently
Correct Answer: C
Rationale: The correct answer is C: Raise the side rails up when the client is in bed. This action helps prevent falls and injuries by providing a physical barrier to keep the client from rolling out of bed. Keeping the television on (choice A) does not directly address client safety. Placing the bedside table at the foot of the bed (choice B) may not prevent falls or injuries. Assisting the client to the toilet frequently (choice D) is important for personal care but does not directly reduce the risk for client injury.
Which of the following findings should the nurse identify as the priority?
- A. Xerostomia
- B. Client reports a pain level of 6 on a scale from 0 to 10
- C. Excoriation of the skin on the neck and chest
- D. Dysphagia
Correct Answer: D
Rationale: The correct answer is D: Dysphagia. Dysphagia poses the highest risk of aspiration, malnutrition, and dehydration. Priority is given to life-threatening or potentially life-threatening issues. Xerostomia (A) is uncomfortable but not immediately life-threatening. Pain level (B) can be managed with medication. Excoriation of the skin (C) can be treated topically.
Which of the following actions should the nurse take first?
- A. Review the client's allergy history.
- B. Monitor the client's temperature.
- C. Check the client's latest white blood cell(WBC) count.
- D. Explain the purpose of the medication to the client.
Correct Answer: A
Rationale: The correct answer is A: Review the client's allergy history. This should be done first to prevent potential harm to the client from allergic reactions. Knowing the client's allergy history helps the nurse identify any potential risks associated with administering medications. Monitoring temperature (B) and checking WBC count (C) are important but come after ensuring the safety of medication administration. Explaining the purpose of medication (D) is important but should be done after ensuring the client's safety.
A nurse is assessing a client who received hydromorphone 4mg IV 15 min ago. The client has a respiratory rate of 10/min. the nurse should prepare to administer which of the following medications?
- A. Naloxone
- B. Flumazenil
- C. Activated charcoal
- D. Atropine
- E. Diphenhydramine
Correct Answer: A
Rationale: The correct answer is A: Naloxone. Hydromorphone is an opioid that can cause respiratory depression. The client's low respiratory rate of 10/min indicates potential opioid overdose. Naloxone is an opioid antagonist that reverses the effects of opioids, such as respiratory depression. Administering naloxone can help restore normal breathing in the client. Flumazenil (B) is used to reverse the effects of benzodiazepines, not opioids. Activated charcoal (C) is used for toxin ingestion, not opioid overdose. Atropine (D) is a medication used for bradycardia, not respiratory depression. Diphenhydramine (E) is an antihistamine and is not indicated in this situation.