Nokea
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) accurately reflects the client's rapid tiring due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported by the symptoms described.
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What is a priority nursing intervention for a client with renal colic?
- A. Encourage fluid intake.
- B. Administer morphine as prescribed.
- C. Apply warm compresses.
- D. Insert a urinary catheter.
Correct Answer: B
Rationale: Morphine effectively manages severe renal colic pain, prioritizing client comfort.
The nurse is monitoring a client after an above-the-knee amputation and notes that blood has saturated through the client and the dressing. The nurse should immediately:
- A. Apply a tourniquet
- B. Assess vital signs
- C. Call the physician
- D. Elevate the surgical extremity with a large pillow
Correct Answer: C
Rationale: Blood saturating the dressing post-amputation suggests significant bleeding, a potential emergency. The nurse should immediately call the physician for evaluation and intervention. Applying a tourniquet is extreme and requires an order, assessing vital signs is secondary, and elevating with a pillow may not address the bleeding source.
A client with a large goiter is scheduled for a subtotal thyroidectomy to treat thyrotoxicosis. Saturated solution of potassium iodide (SSKI) is prescribed preoperatively for the client. The primary reason for using this drug is that it helps:
- A. Slow progression of exophthalmos.
- B. Reduce the vascularity of the thyroid gland.
- C. Decrease the body's ability to store thyroxine.
- D. Increase the body's ability to excrete thyroxine.
Correct Answer: B
Rationale: SSKI reduces the vascularity of the thyroid gland, making surgery safer by decreasing the risk of bleeding. It does not primarily affect exophthalmos, thyroxine storage, or excretion.
The nurse is assisting with a bone marrow aspiration and biopsy. In which order, from first to last, should the nurse complete the following tasks?
- A. Verify the client has signed an informed consent.
- B. Position the client in a side-lying position.
- C. Clean the skin with an antiseptic solution.
- D. Apply ice to the biopsy site.
Correct Answer: C,A,B,D
Rationale: First, the nurse must verify that the client has voluntarily signed a consent form before the procedure begins, and check that the client understands the procedure. The nurse then positions the client in a side-lying, or lateral decubitus, position with the affected side up. Then the nurse should clean the skin site and surrounding area with an antiseptic solution such as Betadine before the health care provider collects the specimen. When the procedure is finished, the nurse must apply ice to the biopsy site to reduce pain.
A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy would be to:
- A. Decrease secretions.
- B. Instruct the client in caring for the tracheostomy.
- C. Relieve anxiety related to the tracheostomy.
- D. Maintain a patent airway.
Correct Answer: D
Rationale: Maintaining a patent airway is the priority goal post-laryngectomy with a new tracheostomy to ensure adequate oxygenation and prevent respiratory distress.