Nokea
The home health hospice nurse visits a client who is newly prescribed extended-release oxycodone 40 mg orally, scheduled every 12 hours to treat severe chronic cancer pain. Which information is most important to reinforce to the client’s caregiver?
- A. Administer the medication around the clock even if the client denies having pain
- B. Avoid administering with immediate-release opioids to prevent respiratory depression
- C. Change the dosage and frequency to 20 mg every 6 hours if breakthrough pain occurs
- D. Request a tapered dose from the health care provider if pain decreases to prevent tolerance
Correct Answer: A
Rationale: Around-the-clock dosing maintains pain control in cancer, preventing peaks and troughs. Combining with immediate-release opioids is common, dosage changes require provider orders, and tapering is less critical in terminal care.
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A client comes into the community health center upset and crying stating 'I will die of cancer now that I have this disease.' And then the client hands the nurse a paper with one word written on it: 'Pheochromocytoma.' Which response should the nurse state initially?
- A. Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body.
- B. This tumor can be treated effectively with chemotherapy.
- C. Surgery is always required to remove this type of tumor.
- D. This condition is always fatal within a few months.
Correct Answer: A
Rationale: Pheochromocytomas usually aren't cancerous (malignant). But they may be associated with cancerous tumors in other parts of the body, providing reassurance and accurate information to alleviate the client's fear.
A client has a serum glucose of 385 mg/dl. Which of these orders would the nurse question first?
- A. Repeat glycohemoglobin in 24 hours
- B. Document Accu-checks, intake and output every 4 hours
- C. Humulin N 20 units IV push
- D. IV fluids of 0.9% normal saline at 125 ml per hour
Correct Answer: C
Rationale: Regular insulin is the only insulin that can be given by the intravenous route. Humulin N is not suitable for IV administration, making this the priority order to question.
The orthopedic health care provider instructs a client with a fractured right femur, who has been non-weight bearing for the past 5 weeks, to progress to full-weight bearing on the right leg. Which advanced crutch gait that most closely resembles normal walking should the nurse reinforce when teaching the client?
- A. 2-point gait
- B. 3-point gait
- C. 4-point gait
- D. 5-point gait
Correct Answer: A
Rationale: The 2-point gait mimics normal walking, alternating crutch and opposite leg, suitable for full-weight bearing. 3-point is for non-weight bearing, 4-point is slower, and 5-point does not exist.
The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?
- A. Section A
- B. Section B
- C. Section C
- D. Section D
Correct Answer: A
Rationale: Bubbling in the water seal chamber indicates an air leak from the lung or tubing. The suction control chamber bubbles with suction, and the collection chamber collects fluid, not air.
A client who has Mycoplasma pneumonia needs to go to the radiology department for a chest x-ray. What should the client wear?
- A. A face shield
- B. A surgical mask
- C. An N95 respirator
- D. Gloves and a gown
Correct Answer: B
Rationale: A surgical mask prevents droplet transmission of Mycoplasma pneumonia during transport, protecting others.