Nokea
The client has been in a body cast for the past 2 days to treat numerous broken vertebrae from a fall. The client is reporting dyspnea, vomiting, epigastric pain, and abdominal distention. Which action demonstrates the nurse's best clinical judgment?
- A. Immediately notify the health care provider.
- B. Initiate oxygen at 2 liters per nasal cannula.
- C. Place ice packs around the outside of the cast.
- D. Administer ondansetron prescribed q6h prn.
Correct Answer: A
Rationale: A. The nurse should immediately notify the HCP. A window in the abdominal portion of the cast or bivalving is needed to relieve the pressure.
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The client tells the nurse, 'My father is furious with me. He does not want me to ride a motorcycle.' Which response by the nurse is most appropriate?
- A. As they say, 'Father knows best.''
- B. I'll be sure it is a safe.'
- C. It can be frustrating when you disagree with your father.'
- D. I think you should obey your father's wishes.'
Correct Answer: C
Rationale: Acknowledging the client's frustration validates their feelings without judgment, fostering therapeutic communication. The other responses either dismiss the client's emotions or impose the nurse's opinion, which is inappropriate.
Which explanation by the nurse is best when the parents ask how their child with Duchenne muscular dystrophy will be treated knowing that the life expectancy is limited?
- A. "Due to your child's cognitive impairment, your child will be unaware of a shortened life."
- B. "We will focus on maximizing your child's abilities and promoting your child's comfort."
- C. "There is not enough known about this disease to know what will happen in the future."
- D. "Nothing is likely to happen for a long time; we'll deal with it when the time comes."
Correct Answer: B
Rationale: Treatment for DMD focuses on maximizing function and comfort to improve quality of life.
The Jewish client with peripheral vascular disease is scheduled for a left AKA. Which question is most important for the operating room nurse to ask the client?
- A. Have you made any special arrangements for your amputated limb?'
- B. What types of food would you like to eat while you're in the hospital?'
- C. Would you like a rabbi to visit you while you are in the recovery room?'
- D. Will you start checking your other foot at least once a day for cuts?'
Correct Answer: A
Rationale: Jewish cultural practices may require special handling of amputated limbs (e.g., burial); this question respects beliefs. Food, rabbi visits, and foot checks are secondary.
Which assessment finding would the nurse consider a likely adverse effect of the client's methotrexate (Rheumatrex) therapy?
- A. Constipation
- B. Arrhythmia
- C. Mouth sores
- D. Chest pain
Correct Answer: C
Rationale: Mouth sores (stomatitis) are a common adverse effect of methotrexate due to its impact on rapidly dividing cells, like those in the oral mucosa. The other symptoms are less commonly associated.
The nurse would be correct to request a consultation with a dietitian if the client chooses a meal that includes which food?
- A. Fish
- B. Milk
- C. Eggs
- D. Liver
Correct Answer: D
Rationale: Liver is high in purines, which exacerbate gout.