Nokea
Immediately after a lumbar laminectomy, the nurse administers ondansetron hydrochloride (Zofran) to the client as ordered. The nurse determines that the drug is effective when which of the following is controlled?
- A. Muscle spasms.
- B. Nausea.
- C. Shivering.
- D. Dry mouth.
Correct Answer: B
Rationale: Ondansetron is an antiemetic, effective when nausea is controlled.
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A client with a total hip replacement asks about resuming sexual activity. Which response by the nurse is most appropriate?
- A. Wait at least 3 months post-surgery.'
- B. Avoid positions that flex the hip beyond 90 degrees.'
- C. Resume when you feel no pain.'
- D. Use a soft mattress for comfort.'
Correct Answer: B
Rationale: Avoiding excessive hip flexion prevents dislocation during sexual activity post-hip replacement.
The nurse in the emergency department (ED) is caring for a 62-year-old male client.
Item 6 of 6
Triage Note
1700:
• The client was brought to the ED after collapsing on a tennis court.
• Vital signs: BP 94/57, T 105° F (40.5° C), P 115, RR 26, Pulse oximetry 95% on room air. • The client is lethargic and confused. Skin is pale, and there is some perspiration on the forehead. Thready peripheral pulses, clear lung fields bilaterally, tachypnea, shallow respirations.
Which two (2) findings in the nurses' note would require immediate follow-up and reported to the physician?
- A. Rectal temperature
- B. Generalized shivering
- C. Urine output
- D. Assessment of the peripheral pulses
- E. Client reports of thirst
Correct Answer: B,C
Rationale: Generalized shivering may indicate worsening hypothermia or a cooling blanket complication, and low urine output suggests renal hypoperfusion or acute kidney injury, both requiring immediate physician notification. Temperature (A), pulses (D), and thirst (E) are expected or less urgent.
A male client who has been taking warfarin (Coumadin) has been admitted with severe acute rectal bleeding and the following laboratory results: International Normalized Ratio (INR), 8; hemoglobin, 11 g/dL; and hematocrit, 33%. Which of the following physician orders should the nurse expect to implement initially? Select all that apply.
- A. Administer I.V. dextrose 5% in 0.45% normal saline solution.
- B. Schedule client for a sigmoidoscopy in the morning.
- C. Give 1 unit fresh frozen plasma (FFP).
- D. Administer vitamin K (AquaMEPHYTON) 2.5 mg.
- E. Begin giving polyethylene glycol-electrolyte solution (GoLYTELY) in preparation for sigmoidoscopy.
- F. Administer Fleet enema.
Correct Answer: C,D
Rationale: An INR of 8 indicates excessive anticoagulation from warfarin, causing severe bleeding. Initial management includes administering fresh frozen plasma (FFP) to replace clotting factors and vitamin K to reverse warfarin's effects. Dextrose/saline, sigmoidoscopy preparation, and enemas are not immediate priorities.
A nurse is providing education in a community setting about general measures to avoid excessive sun exposure. Which of the following recommendations is appropriate?
- A. Apply sunscreen only after going into the water.
- B. Avoid peak exposure hours from 9 a.m. to 1 p.m.
- C. Wear loosely woven clothing for added ventilation.
- D. Apply sunscreen with a sun protection factor (SPF) of 15 or more before sun exposure.
Correct Answer: D
Rationale: Applying sunscreen with SPF 15 or higher before sun exposure is a key measure to prevent UV damage. Sunscreen should be applied before water exposure, peak hours are 10 a.m. to 4 p.m., and tightly woven clothing is better for protection.
A 68-year-old female client on day 2 after hip surgery has no cardiac history but reports having chest heaviness. The first nursing action should be to:
- A. Inquire about the onset, duration, severity, and precipitating factors of the heaviness.
- B. Administer oxygen via nasal cannula.
- C. Offer pain medication for the chest heaviness.
- D. Inform the physician of the chest heaviness.
Correct Answer: A
Rationale: Assessing the characteristics of chest heaviness clarifies whether it is cardiac (e.g., angina) or non-cardiac, guiding further actions like oxygen or physician notification.