Nokea
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
- A. Document the site where the medication was given.
- B. Notify the healthcare provider of the allergic response.
- C. Elevate the area and apply light pressure over the site.
- D. Apply a cold pack to the area for twenty minutes.
Correct Answer: A
Rationale: Wheal is normal and should be documented.
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The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize that the client is at greater risk for the development of which complication?
- A. Fibromyalgia
- B. Peptic ulcer disease.
- C. Hypertension
- D. Hypothyroidism.
Correct Answer: C
Rationale: OSA increases blood pressure via hypoxia.
An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?
- A. Teach the client alternative ways to manage chronic pain.
- B. Instruct the client to take the morphine sulfate every 12 hours as prescribed.
- C. Tell the client to continue taking the morphine sulfate with severe pain.
- D. Explain the risk of drug addiction from long-term pain medications.
Correct Answer: B
Rationale: Scheduled dosing maintains consistent pain control.
A client with emphysema tells the nurse that sitting upright in bed makes breathing easier. Which instruction is most important for the nurse to provide the assigned unlicensed assistive personnel (UAP)?
- A. Offer fruit juice at least twice during both the day and evening shifts.
- B. Encourage the client to eat all of the meals that are sent.
- C. Lower the bed prior to helping the client to move up in bed.
- D. Have the client hold a pillow over the abdomen to cough and deep breathe.
Correct Answer: D
Rationale: Splinting aids breathing.
When assessing a client with a serum potassium level of 2.5 mEq/L, which intervention is most important for the nurse to implement?
- A. Observe color and amount of urine.
- B. Determine apical pulse rate and rhythm.
- C. Compare muscle strength bilaterally.
- D. Assess strength of deep tendon reflexes.
Correct Answer: B
Rationale: Hypokalemia risks arrhythmias; pulse is critical.
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home, and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
- A. Bowel incontinence.
- B. Impaired bed mobility.
- C. Fluid volume deficit.
- D. Caregiver role strain.
Correct Answer: C
Rationale: Dehydration from diarrhea is life-threatening.