Nokea
In the oliguric phase of acute renal failure, the nurse should assess the client for:
- A. Pulmonary edema.
- B. Metabolic alkalosis.
- C. Hypotension.
- D. Hypokalemia.
Correct Answer: A
Rationale: Pulmonary edema is a risk in the oliguric phase due to fluid overload from reduced urine output.
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A client who is taking Bufferin Arthritis Strength caplets develops prolonged bleeding from a superficial skin injury on the forearm. The nurse should tell the client to do which of the following first?
- A. Place the forearm under a running stream of lukewarm water.
- B. Pat the injury with a dry washcloth.
- C. Wrap the entire forearm from the wrist to the elbow.
- D. Apply an ice pack for 20 minutes.
Correct Answer: C
Rationale: Bufferin (aspirin) impairs platelet function, prolonging bleeding. The first action is to apply pressure by wrapping the forearm to control bleeding. Running water or patting may not provide sufficient pressure, and ice is a secondary measure after bleeding is controlled.
A client has been in the position shown in the figure for surgery. The nurse should document that the client has been in which of the following positions?
- A. Reverse Trendelenburg.
- B. Low Fowler’s.
- C. High lithotomy.
- D. Prone.
Correct Answer: C
Rationale: The client is in the lithotomy position. The reverse Trendelenburg position is when the client is lying supine with the head lower than the rest of the body. A low Fowler’s position is when the client is sitting up at a 30- to 45-degree angle. The prone position is when the client is lying face down.
Which of the following actions should the nurse plan to do first when caring for a client who is experiencing spiritual distress?
- A. Make a referral to a member of the clergy.
- B. Explain the major beliefs of different religions.
- C. Suggest reading material.
- D. Help the client explore his or her own values and beliefs.
Correct Answer: D
Rationale: Helping the client explore their own values and beliefs is the first step in addressing spiritual distress, as it establishes a foundation for personalized spiritual support.
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.
What should the nurse do first when a client with a head injury begins to have clear drainage from his nose?
- A. Compress the nares.
- B. Tilt the head back.
- C. Give the client tissues to collect the fluid.
- D. Administer an antihistamine for postnasal drip.
Correct Answer: C
Rationale: Clear drainage from the nose after a head injury may indicate cerebrospinal fluid (CSF) leakage, a serious condition. The priority is to collect the fluid for analysis to confirm CSF and avoid infection, making providing tissues the first action. Compressing the nares or tilting the head back could increase intracranial pressure or contaminate the fluid, and an antihistamine is inappropriate without confirming the cause.