Nokea
During the first 24 hours after thrombolytic treatment for an ischemic stroke, the primary goal is to control the client's:
- A. Pulse.
- B. Respirations.
- C. Blood pressure.
- D. Temperature.
Correct Answer: C
Rationale: Controlling blood pressure is the primary goal post-thrombolytic therapy to prevent hemorrhagic transformation. Pulse, respirations, and temperature are monitored but are secondary.
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A client returned to the recovery room after a dilatation and curettage has the postoperative medication orders shown in the chart. What should the nurse do next?
- A. Ask the client to rate the intensity of her painon a scale of 1 to 10 and administer the analgesia according to the intensity of the pain.
- B. Administer the Demerol fi rst because the client had surgery today.
- C. Administer the Tylenol #3 fi rst, and if it does not relieve the pain in 2 hours, administer the Demerol.
- D. Administer the Motrin fi rst and if it does not relieve the pain, administer the Demerol.
Correct Answer: A
Rationale: The nurse must fi rst assess the intensity of the client’s pain before selecting the correct analgesia. A high score would necessitate administering the meperidine (Demerol). If the intensity rating is low, an oral analgesic would be appropriate. If acetaminophen (Tylenol #3) is given without assessing the intensity of the client’s pain, the nurse must then wait 4 hours before administering another analgesic
The nurse is preparing a community education program about preventing hepatitis B infection. Which of the following would be appropriate to incorporate into the teaching plan?
- A. Hepatitis B is relatively uncommon among college students.
- B. Frequent ingestion of alcohol can predispose an individual to development of hepatitis B.
- C. Good personal hygiene habits are most effective at preventing the spread of hepatitis B.
- D. The use of a condom is advised for sexual intercourse.
Correct Answer: D
Rationale: Condom use (D) prevents hepatitis B transmission via sexual contact. Hepatitis B is not uncommon in college students (A). Alcohol (B) is unrelated to hepatitis B transmission. Hygiene (C) is less effective than barrier protection.
To help minimize the risk of postoperative respiratory complications after a hypophysectomy, during preoperative teaching, the nurse should instruct the client how to:
- A. Use blow bottles.
- B. Turn in bed.
- C. Take deep breaths.
- D. Cough.
Correct Answer: C
Rationale: Deep breathing exercises post-hypophysectomy help expand lungs and prevent atelectasis, reducing respiratory complications.
After surgery and insertion of a total joint prosthesis, a client develops severe sudden pain and an inability to move the extremity. The nurse correctly interprets these findings as indicating which of the following?
- A. A developing infection.
- B. Bleeding in the operative site.
- C. Joint dislocation.
- D. Glue seepage into soft tissue.
Correct Answer: C
Rationale: Sudden pain and inability to move suggest joint dislocation, a surgical emergency.
When assessing the client with Hodgkin's disease, the nurse should observe the client for which of the following?
- A. Herpes zoster infections.
- B. Discolored teeth.
- C. Hemorrhage.
- D. Hypercellular immunity.
Correct Answer: A
Rationale: Hodgkin's disease impairs immune function, increasing the risk of infections like herpes zoster (shingles). Discolored teeth, hemorrhage, and hypercellular immunity are not typical findings.