Nokea
A patient with chronic cancer-related pain has started using MS Contin for pain control and has developed common side effects of the drug. The nurse reassures the patient that tolerance will develop to most of these side effects but that continued treatment will most likely be required for what?
- A. Pruritus
- B. Constipation
- C. Dizziness
- D. Nausea and vomiting
Correct Answer: B
Rationale: The correct answer is B. Constipation is a persistent side effect of opioids.
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Which drainage is drained with a Hemovac?
- A. Bile
- B. Urine
- C. Gastric contents
- D. Wound drainage
Correct Answer: D
Rationale: Hemovacs are used for wound drainage, collecting serosanguinous fluid.
Miss Clement plans to increase her running program to 30 miles a week. Which fluid would be most desirable to avoid dehydration?
- A. Tomato juice
- B. Ice-cold mineral water
- C. Beer
- D. Lemonade
Correct Answer: B
Rationale: Ice-cold mineral water is the best choice for hydration as it replenishes fluids without added sugars or alcohol, which can dehydrate.
The nurse is caring for a client with end stage renal disease. What action should the nurse take to assess for patency in a fistula used for hemodialysis?
- A. Observe for edema proximal to the site.
- B. Irrigate with 5 mls of 0.9% Normal Saline.
- C. Palpate for a thrill over the fistula.
- D. Check color and warmth in the extremity.
Correct Answer: C
Rationale: A thrill confirms blood flow through the fistula.
A client has a chest tube in place connected to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?
- A. Oxygen saturation of 95%
- B. No fluctuations in the water seal chamber
- C. No reports of pleuritic chest pain
- D. Occasional bubbling in the water-seal chamber
Correct Answer: B
Rationale: The correct answer is B: No fluctuations in the water seal chamber. This finding indicates that the lung has re-expanded because it means there is no air leaking from the lung into the pleural space, causing fluctuations in the water seal chamber. Option A, oxygen saturation of 95%, is not directly related to lung re-expansion. Option C, no reports of pleuritic chest pain, is a subjective symptom and does not provide a direct indication of lung re-expansion. Option D, occasional bubbling in the water-seal chamber, indicates air is escaping from the lung into the pleural space, suggesting incomplete lung re-expansion.
A client who experienced a femur fracture 8 hr ago now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?
- A. Provide high-flow oxygen.
- B. Check the client for a positive Chvostek's sign.
- C. Administer an IV vasopressor medication.
- D. Monitor the client for headache.
Correct Answer: A
Rationale: Step 1: Recognize potential complications of femur fracture - fat embolism syndrome (FES) can cause sudden onset dyspnea and chest pain.
Step 2: Provide high-flow oxygen to improve oxygenation and stabilize the client's condition.
Step 3: Oxygen therapy takes priority to address potential respiratory compromise and prevent further deterioration.
Summary:
- Option B (Chvostek's sign) is unrelated to the client's current symptoms.
- Option C (IV vasopressor) is not indicated for FES.
- Option D (monitor for headache) is not a priority when the client is experiencing dyspnea and chest pain.