Nokea
Nurses caring for clients who have cancer and are taking opioids need to assess for all of the following except:
- A. tolerance.
- B. constipation.
- C. sedation.
- D. addiction.
Correct Answer: D
Rationale: Addiction is not of primary concern when treating the pain of terminally ill clients. Clients with cancer who are taking opioid analgesics can develop tolerance, constipation, and sedation.
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An LPN is caring for a primarily bedridden client. Which finding should be of least concern?
- A. swollen feet
- B. brown discoloration above the ankles
- C. leg pain
- D. capillary refill time of 3 seconds on the big toe
Correct Answer: D
Rationale: Capillary refill time of longer than three seconds may indicate inadequate blood flow; capillary refill time of 2-3 seconds is a normal finding. Swollen feet, brown discoloration, and leg pain may be signs of venous insufficiency to the lower extremities.
What is the most effective way to prevent skin breakdown?
- A. assistive devices
- B. repositioning
- C. topical medications
- D. avoiding tape and Bandaids™
Correct Answer: B
Rationale: Repositioning is the most effective way to prevent skin breakdown.
The NSAID that is comparable to morphine in efficacy is:
- A. Feldene.
- B. Stodal.
- C. Toradol.
- D. Elavil.
Correct Answer: C
Rationale: Toradol is the first injectable NSAID equal to morphine in efficacy.
While repositioning the client, the LPN notices a shallow, open ulcer on the sacrum with partial-thickness skin loss. What is the classification stage of this ulcer?
- A. Stage I
- B. Stage IV
- C. Stage II
- D. Stage III
Correct Answer: C
Rationale: An ulcer is classified as stage II when the skin is not intact and there is partial-thickness skin loss. An ulcer with full-thickness skin loss would be stage III.
Following an automobile accident that caused a head injury to an adult client, the nurse observes that the client sleeps for long periods of time. The nurse determines that the client has experienced injury to the:
- A. hypothalamus.
- B. thalamus.
- C. cortex.
- D. medulla.
Correct Answer: A
Rationale: The hypothalamus, when injured, can cause fluctuations and disruptions in sleep patterns.