Nokea
Nursing responsibilities for the client with a patient-controlled analgesia (PCA) system should include:
- A. Reassuring the client that pain will be relieved.
- B. Documenting the client's response to pain medication on a routine basis.
- C. Instructing the client to continue pressing the system's button whenever pain occurs.
- D. Titrating the client's pain medication until the client is free from pain.
Correct Answer: B
Rationale: Documenting the client's response to PCA is a key nursing responsibility to monitor efficacy and safety. Reassuring complete relief, instructing to press repeatedly, or titrating to pain-free status may be unrealistic or unsafe.
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Which of the following nursing assessment findings indicates hypovolemic shock in a client who has had a 15% blood loss?
- A. Pulse rate less than 60 bpm.
- B. Respiratory rate of 4 breaths/minute.
- C. Pupils unequally dilated.
- D. Systolic blood pressure less than 90 mm Hg.
Correct Answer: D
Rationale: A 15% blood loss can cause hypovolemic shock, with early signs including hypotension (systolic BP <90 mm Hg) due to reduced circulating volume. Bradycardia, low respiratory rate, and unequal pupils are not typical findings.
An advantage of using biologic burn grafts such as porcine (pigskin) grafts is that they appear to help:
- A. Encourage formation of tough skin.
- B. Promote the growth of epithelial tissue.
- C. Provide for permanent wound closure.
- D. Facilitate development of subcutaneous tissue.
Correct Answer: B
Rationale: Porcine grafts act as a temporary biological dressing, promoting epithelial tissue growth by providing a protective barrier and stimulating healing. They do not form tough skin, provide permanent closure, or directly affect subcutaneous tissue.
When teaching a client to deep breathe effectively after a lobectomy, the nurse should instruct the client to do which of the following?
- A. Occurnt the abdominal muscles, take a slow deep breath through the nose and hold it for 3 to 5 seconds, then exhale.
- B. Contract the abdominal muscles, take a deep breath through the mouth, and exhale slowly as if trying to blow out a candle.
- C. Relax the abdominal muscles, take a slow deep breath through the nose, and hold it for 3 to 5 seconds.
- D. Relax the abdominal muscles, take a deep breath through the mouth, and exhale slowly over 10 seconds.
Correct Answer: C
Rationale: Effective deep breathing post-lobectomy involves relaxing abdominal muscles, taking a slow nasal breath, holding it 3–5 seconds, and exhaling to expand lungs. Contracting muscles or mouth breathing is less effective.
A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
The nurse is preparing to transfuse fresh frozen plasma (FFP) to a client. Which of the following actions would be appropriate for the nurse to take?
- A. Obtain baseline platelet count
- B. Verify ABO compatibility
- C. Infuse over two to four hours
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: FFP requires ABO compatibility verification to prevent transfusion reactions, as it contains plasma proteins and antibodies. Platelet counts are irrelevant to FFP, infusion time is typically 30–60 minutes, and an ECG is not routinely required.