Nokea
The client received electroconvulsive therapy (ECT) an hour ago and tells the nurse that he has a headache. Which response by the nurse is best?
- A. A headache is common after ECT.
- B. I will get some acetaminophen (Tylenol) for you.
- C. A nap will help you feel better.
- D. A tapur command and then let me know how you feel.
Correct Answer: B
Rationale: Offering acetaminophen addresses the client's complaint directly and safely, as headaches are a common side effect of ECT. Informing the client that headaches are common does not provide relief, and a nap or unclear commands are not appropriate responses.
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A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which of the following ways?
- A. Cooled.
- B. Humidified.
- C. At a low flow rate.
- D. Through nasal cannula.
Correct Answer: C
Rationale: Low flow rate oxygen prevents CO2 retention in emphysema clients, reducing the risk of depressed ventilation.
A 10-month-old child has cold symptoms. The mother asks how she can clear the infant's nose. Which of the following would be the nurse's best recommendation?
- A. Use a cool air vaporizer with plain water.
- B. Use saline nose drops and then a bulb syringe.
- C. Blow into the child's mouth to clear the infant's nose.
- D. Administer a nonprescription vasoconstrictive nose spray.
Correct Answer: B
Rationale: Saline nose drops followed by bulb syringe suction is safe and effective for clearing nasal congestion in infants. Vaporizers help with humidity, but saline and suction directly clear the nose.
The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
- A. Can you describe what the pain feels like?
- B. Can you rate the pain on a scale of 1 to 10 ?
- C. Did you get any relief from the last dose of pain medication?
- D. Can you compare this pain to the pain you felt before surgery?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.
The nurse is assessing a client with irreversible shock. The nurse should document which of the following?
- A. Increased alertness.
- B. Circulatory collapse.
- C. Hypertension.
- D. Diuresis.
Correct Answer: B
Rationale: Irreversible shock is characterized by circulatory collapse, with failure of vital organs due to inadequate perfusion, a critical finding to document.
The nurse is discharging a client who has been hospitalized for preterm labor. The client needs further instruction when she says:
- A. If I think I have a bladder infection, I need to see my obstetrician.'
- B. If I have contractions, I should contact my health care provider.'
- C. Drinking water may help prevent early labor for me.'
- D. If I travel on long trips, I need to get out of the car every 4 hours.'
Correct Answer: D
Rationale: Clients with preterm labor should get out of the car every 1-2 hours to promote circulation and prevent complications, not every 4 hours, indicating a need for further instruction.