Nokea
The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states:
- A. The machine will administer only the amount that you need to control your pain without any action from you.'
- B. The machine has a locking device that prevents overdosing.'
- C. The machine will administer one large dose every 4 hours to relieve your pain.'
- D. The machine is set to deliver medication only if you need it.'
Correct Answer: B
Rationale: The PCA pump has a lockout mechanism to prevent overdosing, ensuring safe, patient-controlled dosing.
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A client with COPD must have the arterial blood gas (ABG) test and asks the nurse to explain the purpose of the test. Which of the following information should the nurse include? Select all that apply.
- A. ABGs measure the levels of carbon dioxide, oxygen, and acidity in the blood.
- B. ABGs help to evaluate the effectiveness of treatment.
- C. ABGs measure the degree of anemia that has developed.
- D. ABGs can help to determine the need for supplemental oxygen.
Correct Answer: A,B,D
Rationale: ABGs measure CO2, O2, and pH (A), evaluate treatment efficacy (B), and guide oxygen therapy (D). Anemia (C) is assessed via hemoglobin, not ABGs.
A client with AIDS has impaired nutrition because of diarrhea. Which diet selection by the client would indicate a need for further teaching of foods that can worsen the diarrhea?
- A. Tossed salad
- B. Baked chicken
- C. Broiled fish
- D. Steamed rice
Correct Answer: A
Rationale: Raw vegetables in a tossed salad can exacerbate diarrhea in AIDS patients. Baked chicken, broiled fish, and steamed rice are easier to digest and less likely to worsen diarrhea.
A 19-year-old female is admitted to the psychiatric floor after a suicide attempt 3 days ago. With client safety a priority, the nurse should
- A. assign the patient to the room closest to the nursing station.
- B. assign the patient to an open room with a roommate.
- C. assign the patient to a secluded, isolated room.
- D. assign a staff member to stay with the client at all times.
Correct Answer: A
Rationale: Placing the client near the nursing station allows close monitoring without isolation, balancing safety and autonomy. Constant staff presence is resource-intensive and not always necessary.
Which roommate would be most suitable for the 6-year-old male with a fractured femur in Russell's traction?
- A. 16-year-old female with scoliosis
- B. 12-year-old male with a fractured femur
- C. 10-year-old male with sarcoma
- D. 6-year-old male with osteomylitis
Correct Answer: B
Rationale: A 12-year-old male with a similar condition provides age-appropriate companionship and shared care needs.
The client with a myocardial infarction comes to the nurse's station stating that he is ready to go home because there is nothing wrong with him. Which defense mechanism is the client using?
- A. Rationalization
- B. Denial
- C. Projection
- D. Conversion reaction
Correct Answer: B
Rationale: Denial involves refusing to acknowledge a serious condition.