Nokea
The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next?
- A. Bladder distention.
- B. Headache.
- C. Postoperative pain.
- D. Ability to move the legs.
Correct Answer: A
Rationale: Epidural anesthesia can cause urinary retention due to sensory and motor nerve blockade. Assessing for bladder distention is critical to prevent complications like bladder overdistension.
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Propylthiouracil (PTU) is prescribed for a client with Graves' disease. The nurse should teach the client to immediately report which of the following?
- A. Sore throat.
- B. Painful, excessive menstruation.
- C. Constipation.
- D. Increased urine output.
Correct Answer: A
Rationale: Propylthiouracil (PTU) can cause agranulocytosis, a serious condition involving a low white blood cell count, which may present as a sore throat or fever. This requires immediate reporting. The other symptoms are not typically associated with PTU side effects.
A client in the postanesthesia care unit with a left below-the-knee amputation has pain in her left big toe. Which of the following should the nurse do first?
- A. Tell the client it is impossible to feel the pain.
- B. Show the client that the toes are not there.
- C. Explain to the client that her pain is real.
- D. Give the client the prescribed opioid analgesic.
Correct Answer: C
Rationale: Phantom limb pain is real and distressing; acknowledging it validates the client's experience.
A client has had a nasogastric tube connected to low intermittent suction. The client is at risk for which of the following complications?
- A. Confusion.
- B. Muscle cramping.
- C. Edema.
- D. Tremors.
Correct Answer: B
Rationale: Nasogastric suction can cause electrolyte imbalances, such as hypokalemia, leading to muscle cramping due to loss of potassium-rich gastric fluid.
A hospice client's family asks how they will know when death is imminent. The nurse should explain that signs include:
- A. Increased energy and mobility.
- B. Cheyne-Stokes respirations.
- C. Improved blood pressure.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Cheyne-Stokes respirations, characterized by alternating periods of apnea and deep breathing, are a common sign of imminent death.
The nurse is planning a staff development conference about measures to reduce medication errors. It would be appropriate for the nurse to state which actions may help reduce medication errors? Select all that apply.
- A. Timely medication reconciliation
- B. Delay documentation of medication administration to the end of the shift
- C. Delegate medication transcription to unlicensed assistive personnel (UAP)
- D. Limit the use of verbal orders to emergent situations
- E. Place medication dispensing systems in high-traffic areas
Correct Answer: A,D
Rationale: Timely reconciliation and limiting verbal orders reduce errors; delayed documentation, UAP transcription, and high-traffic dispensing systems increase error risk.