Nokea
A serious complication of a total hip replacement is displacement of the prosthesis. What is the primary sign of displacement?
- A. pain on movement and weight bearing
- B. hemorrhage
- C. affected leg appearing 1-2 inches longer
- D. edema in the area of the incision
Correct Answer: A
Rationale: Pain on movement and weight bearing indicates pressure on the nerves or muscles caused by the dislocation. Other symptoms of dislocation include an inability to bear weight and a shortening of the affected leg. Edema is not a primary sign of displacement.
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A client receiving drug therapy with furosemide and digitalis requires careful observation and care. In planning care for this client, the nurse should recognize that which of the following electrolyte imbalances is most likely to occur?
- A. hyperkalemia
- B. hypernatremia
- C. hypokalemia
- D. hypomagnesemia
Correct Answer: C
Rationale: Furosemide, a diuretic, commonly causes potassium loss, leading to hypokalemia, which can potentiate digitalis toxicity, requiring close monitoring.
The major electrolytes in the extracellular fluid are:
- A. potassium and chloride.
- B. potassium and phosphate.
- C. sodium and chloride.
- D. sodium and phosphate.
Correct Answer: C
Rationale: Sodium and chloride are the major electrolytes in the extracellular fluid.
The client being treated for opiate dependence is receiving a buprenorphine/naloxone combination. The nurse understands that the reason for adding naloxone to the treatment with buprenorphine is for what effect?
- A. Prevent opiate intoxication should the client abuse an opiate.
- B. Replace essential nutrients due to malnutrition from drug abuse.
- C. Reduce the incidence of adverse reactions of the buprenorphine.
- D. Induce an adverse reaction if the client uses an opiate while on buprenorphine.
Correct Answer: A
Rationale: Naloxone in buprenorphine/naloxone (Suboxone) blocks opiate receptors, preventing intoxication if opiates are abused.
A client had a colostomy done one day ago. Which of the following is an abnormal finding when assessing the stoma?
- A. Mild edema
- B. Minimal bleeding
- C. Rose color
- D. Dark red color
Correct Answer: D
Rationale: A dark red stoma indicates inadequate blood supply, an abnormal finding requiring intervention. Mild edema, minimal bleeding, and rose color are normal postoperative findings.
The client undergoing detoxification from chronic alcohol abuse is to receive Phenobarbital 120 mg IM and promethazine 50 mg IM. Which explanation by the nurse about using this medication combination is correct?
- A. Promethazine will prevent a potential allergic reaction to the phenobarbital.
- B. Combining promethazine and phenobarbital will have a greater sedative effect.
- C. Promethazine will decrease the nausea from phenobarbital when it is given IM.
- D. Combining these reduces the sedative effects and prevents a ‘hangover' feeling.
Correct Answer: B
Rationale: Promethazine (Phenergan) potentiates the CNS depression of phenobarbital, producing a greater sedative effect.