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A patient 3 hours post-op from a hysterectomy is complaining of intense pain at the incision site. When assessing the patient, the nurse notes a BP of 169/93, pulse 145 bpm, and regular. What action should the nurse take?
- A. Reassure the patient that pain is normal following surgery.
- B. Administer prn Nifedipine and assess the client's response.
- C. Administer prn Meperidine HCL and assess the client's response.
- D. Recheck BP and pulse rate every 20 minutes for the next hour.
Correct Answer: C
Rationale: The correct action for the nurse to take in this situation is to administer prn Meperidine HCL and assess the client's response. A BP of 169/93 and a pulse of 145 bpm indicate pain-related hypertension and sinus tachycardia, which are physiological responses to pain. Treating the cause of the increased pulse rate requires pain medication. Reassuring the patient about normal post-surgery pain is important, but addressing the physiological responses to pain is a priority. Administering Nifedipine, a calcium channel blocker, is not indicated for pain management but for hypertension. Rechecking the BP and pulse rate without addressing the pain directly does not address the underlying issue causing the elevated vital signs.
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The PN is caring for a client with diabetes insipidus. The nurse can expect the lab work to show:
- A. elevated urine osmolarity and elevated serum osmolarity.
- B. decreased urine osmolarity and decreased serum osmolarity.
- C. elevated urine osmolarity and decreased serum osmolarity.
- D. decreased urine osmolarity and elevated serum osmolarity.
Correct Answer: D
Rationale: In diabetes insipidus, the pituitary releases too much antidiuretic hormone (ADH), causing the client to produce a large amount of dilute urine (decreased osmolarity) and leading to dehydration (elevated serum osmolarity). Therefore, the correct answer is decreased urine osmolarity and elevated serum osmolarity. Choice C, elevated urine osmolarity and decreased serum osmolarity, is incorrect for diabetes insipidus, as it is more characteristic of syndrome of inappropriate ADH (SIADH). Choices A and B, elevated urine osmolarity and elevated serum osmolarity, and decreased urine osmolarity and decreased serum osmolarity, respectively, are generally not seen in diabetes insipidus, as urine and serum osmolarity typically move in opposite directions in this condition.
A healthcare provider is caring for a patient who has experienced burns to the right lower extremity. According to the Rule of Nines, which of the following percentages most accurately describes the severity of the injury?
- A. 36%
- B. 27%
- C. 18%
- D. 9%
Correct Answer: C
Rationale: According to the Rule of Nines, the right lower extremity accounts for 18% of the total body surface area. The Rule of Nines divides the body into regions, each representing 9% or a multiple of 9%, allowing for a quick estimation of the extent of burns. In this case, the correct answer is 18% as it corresponds to the percentage allocated for each lower extremity. Choices A, B, and D are incorrect as they do not match the standard allocation for the right lower extremity in the Rule of Nines.
What is the best nursing diagnosis for a client with newly diagnosed Diabetes Mellitus?
- A. Impaired Skin Integrity
- B. Knowledge Deficit: New Diabetes Diagnosis
- C. Alteration in Nutrition: More than Body Requirements
- D. Fluid Volume Deficit
Correct Answer: B
Rationale: The correct answer is 'Knowledge Deficit: New Diabetes Diagnosis.' Newly diagnosed diabetics require education on their disease, medications, glucose testing, insulin injections, foot care, and sick-day plans. Choices A and D aim to prevent issues that do not currently exist for the client. Choice C, 'Alteration in Nutrition: More than Body Requirements,' is not the priority diagnosis for a newly diagnosed diabetic. While nutritional adjustments may be required for type I or type II diabetes, providing knowledge and education takes precedence at this stage.
A nurse is instructing a patient about the warning signs of Digitalis side effects. Which of the following side effects should the nurse tell the patient are sometimes associated with excessive levels of Digitalis?
- A. Seizures
- B. Muscle weakness
- C. Depression
- D. Anxiety
Correct Answer: B
Rationale: The correct answer is 'Muscle weakness.' Palpitations and muscle weakness are commonly associated with excessive levels of Digitalis. Seizures, depression, and anxiety are not typically linked to Digitalis toxicity. Seizures could be more related to other medications or conditions, while depression and anxiety are not commonly reported side effects of Digitalis.
The client in the Emergency Department, who has suffered an ankle sprain, should be taught to:
- A. use cold applications to the sprain during the first 24-48 hours.
- B. expect disability to decrease within the first 24 hours of injury
- C. expect pain to decrease within 3 hours after injury.
- D. begin progressive passive and active range of motion exercises immediately.
Correct Answer: A
Rationale: When a client suffers an ankle sprain, the nurse should teach them to use cold applications to the sprain during the first 24-48 hours. Cold applications are believed to produce vasoconstriction and reduce the development of edema. Expecting disability to decrease within the first 24 hours of injury (choice B) is incorrect as disability and pain are anticipated to increase during the first 2-3 hours after injury. Expecting pain to decrease within 3 hours after injury (choice C) is also incorrect as pain and swelling usually increase initially. Beginning progressive passive and active range of motion exercises immediately (choice D) is not recommended; these exercises are usually started 2-5 days after the injury, according to the physician's recommendation. Treatment for a sprain involves support, rest, and alternating cold and heat applications. X-ray pictures are often necessary to rule out any fractures.