Nokea
The doctor has ordered Percocet (oxycodone) for a client following abdominal surgery. The primary objective of nursing care for the client receiving an opiate analgesic is:
- A. Preventing addiction
- B. Alleviating pain
- C. Facilitating mobility
- D. Preventing nausea
Correct Answer: B
Rationale: The primary goal of opiate analgesics like Percocet is to alleviate pain, improving comfort and recovery post-surgery.
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The nurse is working with an unlicensed assistive personnel (UAP). In planning the morning's care, which tasks can the nurse delegate to the UAP? Select all that apply.
- A. feeding a client who has lost the use of his hands
- B. starting an IV in a confused client who pulled her IV out
- C. assisting a stable and alert client up to the bedside commode
- D. checking an apical pulse in a client prior to administering digoxin
- E. ambulating a client in the hall for the first time since surgery to repair a fractured T5 vertebra
Correct Answer: A, C
Rationale: Feeding and assisting a stable client to the commode are within the UAP’s scope, while starting an IV, checking an apical pulse, and ambulating a post-surgical client require nursing judgment.
A 19-year-old male with type 1 diabetes has the flu. The nurse expects what insulin changes may be required during the illness?
- A. stopping all insulin
- B. needing more insulin
- C. needing less insulin
- D. using the same amount of insulin
Correct Answer: B
Rationale: Illness increases insulin resistance due to stress hormones, often requiring more insulin to manage hyperglycemia in type 1 diabetes.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with an acute exacerbation. The nurse notes that the client has a respiratory rate of 28 breaths per minute, is using accessory muscles, and has oxygen saturation of 88% on 2 L/min of oxygen via nasal cannula. Which of the following actions should the nurse take FIRST?
- A. Increase the oxygen flow to 4 L/min.
- B. Administer a bronchodilator as ordered.
- C. Place the client in a high Fowler’s position.
- D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: C
Rationale: positioning in high Fowler’s facilitates breathing and improves oxygenation immediately; other actions may follow based on further assessment
Twenty micrograms (g) are equal to how many milligrams? Record your answer using a decimal number.
Correct Answer: 0.02
Rationale: 1 mg = 1,000 g, so 20 /1,000 = 0.02 mg.
A client is being evaluated for carpel tunnel syndrome. The nurse is observed tapping over the median nerve in the wrist and asking the client if there is pain or tingling. Which assessment is the nurse performing?
- A. Phalen's maneuver
- B. Tinel's sign
- C. Kernig's sign
- D. Brudzinski's sign
Correct Answer: B
Rationale: Tinel's sign involves tapping over the median nerve to elicit pain or tingling, indicating carpal tunnel syndrome. Phalen's maneuver involves wrist flexion, and the others assess meningitis.