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In planning care for the client who has had a stroke, the nurse should obtain a history of the client's functional status before the stroke because?
- A. The rehabilitation plan will be guided by it.
- B. Functional status before the stroke will help predict outcomes.
- C. It will help the client recognize his physical limitations.
- D. The client can be expected to regain much of his functioning.
Correct Answer: A
Rationale: A pre-stroke functional status history guides the rehabilitation plan by setting realistic goals based on prior abilities. Predicting outcomes, recognizing limitations, or expecting full recovery are secondary or unrealistic.
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A 62-year-old female is taking long-acting morphine 120 mg every 12 hours for pain from metastatic breast cancer. She can have 20 mg of immediate-release morphine every 3 to 4 hours as needed for breakthrough pain. The physician should be notified if the client uses more than how many breakthrough doses of morphine in 24 hours?
- A. Seven.
- B. Four.
- C. Two.
- D. One.
Correct Answer: B
Rationale: More than four breakthrough doses (80 mg additional morphine) in 24 hours indicates inadequate baseline pain control, requiring physician notification to adjust the long-acting morphine dose.
A high-carbohydrate, low-protein diet is prescribed for the client with acute renal failure. The intended outcome of this diet is to:
- A. Act as a diuretic.
- B. Reduce demands on the liver.
- C. Help maintain urine acidity.
- D. Prevent the development of ketosis.
Correct Answer: D
Rationale: A high-carbohydrate, low-protein diet provides energy and prevents ketosis by reducing protein breakdown in acute renal failure.
Which assessment is critical for a client with a recent stroke?
- A. Swallowing ability.
- B. Blood glucose.
- C. Cholesterol levels.
- D. Joint mobility.
Correct Answer: A
Rationale: Assessing swallowing ability is critical to prevent aspiration in stroke patients.
The nurse is preparing the discharge of a client with a metal joint. The nurse should instruct the client about which of the following? Select all that apply.
- A. Notify health care providers about the joint prior to invasive procedures.
- B. Avoid use of Magnetic Resonance Imaging (MRI) scans.
- C. Notify airport security that the joint may set off alarms on metal detectors.
- D. Refrain from carrying items weighing more than 5 lb.
- E. Limit fluid intake to 1,000 mL/day.
Correct Answer: A,C
Rationale: Notifying providers and airport security about the metal joint prevents complications and delays. MRI scans are generally safe with modern prostheses.
When beginning I.V. erythropoietin (Epogen, Procrit) therapy, the nurse should do which of the following? Select all that apply.
- A. Checking the hemoglobin levels before administering subsequent doses.
- B. Shaking the vial thoroughly to mix the concentrated white, milky solution.
- C. Keeping the multidose vial refrigerated between scheduled twice-a-day doses.
- D. Administering the medication through the I.V. line without other medications.
- E. Adjusting the initial doses according to the client's changes in blood pressure.
- F. Educating the client to avoid driving and performing hazardous activity during the initial treatment.
Correct Answer: A,C,D,F
Rationale: For IV erythropoietin therapy, the nurse should check hemoglobin levels to monitor response and prevent overcorrection, keep multidose vials refrigerated to maintain stability, administer without mixing with other medications to avoid interactions, and educate about avoiding hazardous activities due to potential side effects like dizziness. Shaking the vial can denature the protein, and dose adjustments are typically based on hematologic response, not blood pressure.