Nokea
On the evening of surgery for total knee replacement, a client wants to get out of bed. To safely assist the client the nurse should do which of the following?
- A. Encourage the client to apply full weightbearing.
- B. Order a walker for the client.
- C. Place a straight-backed chair at the foot of the bed.
- D. Apply a knee immobilizer.
Correct Answer: D
Rationale: A knee immobilizer ensures stability and safety during initial transfers post-surgery.
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The client who has been hospitalized with pancreatitis does not drink alcohol because of her religious convictions. She becomes upset when the physician persists in asking her about alcohol intake. The nurse should explain that the reason for these questions is that:
- A. There is a strong link between alcohol use and acute pancreatitis.
- B. Alcohol intake can interfere with the tests used to diagnose pancreatitis.
- C. Alcoholism is a major health problem, and all clients are questioned about alcohol intake.
- D. The physician must obtain the pertinent facts, regardless of religious beliefs.
Correct Answer: A
Rationale: Alcohol is a primary cause of acute pancreatitis, so questioning its use (A) is essential to identify etiology. Interference with tests (B), general alcoholism screening (C), or disregarding beliefs (D) are not accurate explanations.
Which of the following reasons explains why meperidine (Demerol) is not recommended for chronic cancer-related pain?
- A. It has a high potential for abuse.
- B. It has agonist-antagonist properties.
- C. It must be given intramuscularly to be effective.
- D. It contains a metabolite that causes seizures.
Correct Answer: D
Rationale: Meperidine's metabolite, normeperidine, accumulates with repeated dosing and can cause seizures, making it unsuitable for chronic cancer pain.
Which of the following is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
- A. Treating the underlying cause.
- B. Administering heparin.
- C. Administering warfarin sodium (Coumadin).
- D. Replacing depleted blood products.
Correct Answer: C
Rationale: Warfarin is contraindicated in DIC because it further inhibits clotting factors, worsening bleeding. Treating the underlying cause, administering heparin (to stop clotting), and replacing blood products are standard treatments to manage DIC.
The nurse is teaching a client about newly prescribed isoniazid (INH) for pulmonary tuberculosis. Which of the following statements by the client would require follow up?
- A. I will have to take this medication for three months.
- B. I will need to have my blood drawn periodically to see if I am having an adverse effect to this medication.
- C. I will not be considered infectious if I have three consecutive negative sputum samples.
- D. This medication may make my hands and feet have numbness and tingling sensations.
Correct Answer: A
Rationale: Choice A requires follow-up because isoniazid (INH) treatment for pulmonary tuberculosis typically lasts 6-9 months, not 3 months. Choice B is correct; periodic blood tests monitor for hepatotoxicity. Choice C is correct; three consecutive negative sputum samples indicate non-infectiousness. Choice D is correct; INH can cause peripheral neuropathy, manifesting as numbness and tingling.
The nurse is reviewing the chart information for a client with increased ascites. The data include: temperature 37.2°C; heart rate 118; shallow respirations 26; blood pressure 128/76; and SpO2 89% on room air. Which action should receive priority by the nurse?
- A. Assess heart sounds.
- B. Obtain an order for blood cultures.
- C. Prepare for a paracentesis.
- D. Raise the head of the bed.
Correct Answer: D
Rationale: Low SpO2 (89%) and shallow respirations indicate respiratory compromise, likely from ascites pressing on the diaphragm. Raising the head of the bed (D) improves breathing. Heart sounds (A), blood cultures (B), and paracentesis (C) are secondary.