Nokea
An 80-year-old aphasic CVA client had abdominal surgery 2 days ago. Which of the following puts this client at the highest risk for inadequate pain management?
- A. inability to turn, cough, and breathe deeply
- B. inability to communicate pain
- C. inability to ambulate freely
- D. inability to use a bedside commode
Correct Answer: B
Rationale: The client cannot speak to alert the nurse to his pain state. The nurse needs to provide alternate methods of communication with the client.
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Safety measures for using crutches must be taught to clients. Safety measures for the use of crutches include:
- A. properly fitting crutches with rubber tips at the end that provide a four-point gait.
- B. properly fitting crutches, education in the appropriate gait, and strength in the arms.
- C. crutches that fit the way the client chooses and a gait chosen by client.
- D. both legs touching the floor for all gaits.
Correct Answer: B
Rationale: In addition to the rubber tips on the ends of the crutches, the client needs to know the appropriate gait. Arm strength exercises are important, and it is critical that the client be fitted properly for the crutches.
The postoperative male client has been unable to urinate into the urinal while lying in bed. Which interventions are appropriate to promote voiding for this client who is to be discharged home within a few hours? Select all that apply.
- A. Have the client apply an external condom catheter while lying flat in bed
- B. Assist the client to stand at the bedside to attempt to urinate in a urinal.
- C. Administer a prescribed analgesic if the client is experiencing pain.
- D. Turn on running water so it is heard while the client attempts to void.
- E. Ask the client to imagine being at home and voiding in his own bathroom.
Correct Answer: B,C,D,E
Rationale: B: Standing mimics normal voiding position. C: Pain relief aids relaxation for voiding. D: Running water stimulates the voiding reflex. E: Guided imagery promotes relaxation. A: Condom catheters manage incontinence, not promote voiding.
The LPN is caring for a client with an NG tube, and the RN administers evening medications through the NG tube. The client asks if he can lie down when the nurse leaves the room. What is the most appropriate response?
- A. You can lie down in 1 hour.
- B. You can lie down in 5 minutes if your NG residual is below 50 mLs.
- C. You can lie down in about 30 minutes.
- D. You can lie down now.
Correct Answer: C
Rationale: After administering medication through an NG tube, the client should remain upright for 30 minutes to ensure the medications are absorbed.
The client has dentures, including both upper and lower plates. Which technique should the nurse use to correctly perform oral hygiene for this client?
- A. Wear sterile gloves to remove the lower plate first and then the upper plate.
- B. Use a foam swab to pry the upper and lower plates loose before removing these.
- C. Grasp the upper plate at the front teeth with a piece of gauze and move it prior to removal.
- D. Leave the dentures in the client's mouth and use a toothbrush to brush both denture plates.
Correct Answer: C
Rationale: C: Grasping the upper plate and moving it breaks the suction that holds the plate on the roof of the client's mouth. A: Removing denture plates is a clean procedure, and sterile gloves are not necessary. B: Removing the denture plates with a foam swab to pry the plate could injure the client. D: Dentures must be removed to properly clean the client's mouth and the dentures.
In managing nausea related to Morphine epidural analgesia, the nurse should administer:
- A. Indocin
- B. Codeine
- C. Motrin
- D. Compazine
Correct Answer: D
Rationale: Compazine (prochlorperazine) is an antiemetic effective for opioid-induced nausea, unlike the other options, which are analgesics or anti-inflammatories.