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A postoperative client has a nasogastric (NG) tube following bowel surgery. The orders read, 'acetaminophen 650 PRN for fever above 101°F.' The client has a temperature of 101.4°F. What is the most appropriate nursing action?
- A. Administer the acetaminophen by rectal suppository.
- B. Administer the acetaminophen by elixir through the NG tube and turn suction off for 30 minutes.
- C. Administer the acetaminophen by crushing two tablets, giving it through the NG tube, and turning suction off for 30 minutes.
- D. Call the physician and question the order.
Correct Answer: A
Rationale: A rectal suppository is appropriate with an NG tube on suction, ensuring fever treatment without risking medication loss.
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After admission for elective surgery, an adult says to the nurse, 'They asked me if I had advance directives. I don't even know what that is.' What is the best response by the nurse?
- A. Advance directives are usually written by persons who have a terminal illness. They are not indicated for elective surgery.
- B. An advance directive is a document that tells the medical and nursing staff what your wishes are regarding certain health care items should you not be able to make decisions for yourself.
- C. An advance directive includes information about you and your specific medical history that could be important to care givers if you are not alert.
- D. Advance directives direct your family about your plans for distributing your belongings when you are no longer here.
Correct Answer: B
Rationale: Advance directives specify healthcare preferences for incapacitation, relevant for any adult, clearly explaining their purpose.
The nursing team includes two RNs, one LPN/LVN, and one nursing assistant.
- A. Which client is appropriate for the nursing assistant to care for?
- B. A client with Alzheimer’s requiring assistance with feeding.
- C. A client with osteoporosis complaining of burning on urination.
- D. A client with scleroderma receiving a tube feeding.
- E. A client with cancer who has Cheyne-Stokes respirations.
Correct Answer: A
Rationale: Nursing assistants can care for clients with standard, unchanging procedures like feeding an Alzheimer’s patient. Clients with urinary symptoms, tube feedings, or unstable respirations require RN or LPN assessment and intervention.
Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
- A. Nausea and vomiting
- B. Headache
- C. Dizziness
- D. Papilledema
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.
The nurse is teaching a client with a new diagnosis of heart failure about carvedilol (Coreg). Which of the following instructions should the nurse include?
- A. Take the medication at bedtime.
- B. Report dizziness or lightheadedness.
- C. Stop the medication if symptoms improve.
- D. Avoid checking pulse rate.
Correct Answer: B
Rationale: Dizziness or lightheadedness may indicate hypotension, a carvedilol side effect, requiring reporting. Options A, C, and D are incorrect.
The nurse is caring for a client with an unstable spinal cord injury at the T7 level. Which intervention should take priority in planning care?
- A. Increase fluid intake to prevent dehydration
- B. Place client on a pressure reducing support surface
- C. Use skin care products designed for use with incontinence
- D. Increase caloric intake to aid healing
Correct Answer: B
Rationale: Place client on a pressure reducing support surface. This prevents skin breakdown due to immobility and reduced sensation.