Nokea
The client with a fractured tibia has been taking methocarbamol (Robaxin). Which of the following indicate that the drug is having the intended effect?
- A. Lack of infection.
- B. Reduction in itching.
- C. Relief of muscle spasms.
- D. Decrease in nervousness.
Correct Answer: C
Rationale: Methocarbamol is a muscle relaxant, effective when muscle spasms are relieved.
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The nurse teaches the client with a urinary diversion to attach the appliance to a standard urine collection bag at night. The most important reason for doing this is to prevent.
- A. Unlike reflux into the stoma.
- B. Appliance separation.
- C. Urine leakage.
- D. The need to restrict fluids.
Correct Answer: C
Rationale: A night collection bag prevents urine leakage by providing adequate capacity, reducing the risk of appliance overflow during sleep.
As part of the client's discharge planning after a subtotal gastrectomy, the nurse has identified Imbalanced nutrition: Less than body requirements as a major nursing diagnosis. To help the client meet nutritional goals at home, the nurse should develop a plan of care that includes which of the following interventions?
- A. Instruct the client to increase the amount eaten at each meal.
- B. Encourage the client to eat smaller amounts more frequently.
- C. Explain that if vomiting occurs after a meal, nothing more should be eaten that day.
- D. Inform the client that bland foods are typically less nutritional and should be used minimally.
Correct Answer: B
Rationale: Smaller, frequent meals help prevent dumping syndrome and ensure adequate nutrition post-gastrectomy. Large meals, fasting after vomiting, or avoiding bland foods are not appropriate.
A client who was a victim of a gunshot wound was treated in the emergency department and died. What should the nurse direct the unlicensed assistive personnel (UAP) to do during postmortem care? Select all that apply.
- A. Remove all tubes and I.V. lines.
- B. Cover the body with a sheet.
- C. Notify the family.
- D. Transport the body to the morgue.
- E. Notify the chaplain.
Correct Answer: B,D
Rationale: UAP can cover the body and transport it to the morgue. Removing tubes may be restricted due to forensic needs, and notifying family or chaplain is typically a nurse's responsibility.
What is a goal of care for a client with acute renal failure?
- A. Maintain urine output of 30 mL/hour.
- B. Keep potassium above 5.5 mEq/L.
- C. Increase protein intake.
- D. Limit ambulation.
Correct Answer: A
Rationale: Maintaining adequate urine output indicates improving renal function.
The nurse is assessing a client with anemia. In order to plan nursing care, the nurse should focus the assessment on which of the following?
- A. Decreased salivation.
- B. Bradycardia.
- C. Cold intolerance.
- D. Nausea.
Correct Answer: C
Rationale: Cold intolerance is a common symptom of anemia due to reduced oxygen-carrying capacity, and assessing it helps plan supportive care.