Nokea
The nurse begins to assist with ambulation of a 9-year-old client who is 1 day postoperative appendectomy when the child cries out, 'It hurts too much. I can't do it.' Which action should the nurse complete first?
- A. Administer a PRN analgesic and monitor for adverse effects
- B. Ask the client to point to a numeric scale to indicate pain level
- C. Come back later in the day to attempt ambulation again
- D. Encourage the client to walk to promote blood circulation
Correct Answer: B
Rationale: Assessing pain level using a numeric scale is the first step to quantify the child's pain and determine the need for analgesics or other interventions. Administering analgesics without assessment is premature, delaying ambulation avoids addressing pain, and encouraging walking ignores the child's distress.
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The nurse is reinforcing information to a diabetic client with a new prescription for metoclopramide. Which of the following side effects must the nurse remind the client to report immediately to the health care provider? Select all that apply.
- A. Excess blinking of eyes
- B. Dry mouth
- C. Dull headache
- D. Lip smacking
- E. Puffing of cheeks
Correct Answer: A,D,E
Rationale: Metoclopramide can cause tardive dyskinesia, with symptoms like excess blinking , lip smacking , and cheek puffing , requiring immediate reporting. Dry mouth and headache are common and less urgent.
The nurse in the emergency department is caring for a client who was involved in a motor vehicle collision. Which of the following diagnostic test results would best determine the client's oxygenation and ventilation status?
- A. peak expiratory flow rate reading
- B. arterial blood gas analysis
- C. pulse oximetry reading
- D. CT scan of the chest
Correct Answer: B
Rationale: Arterial blood gas provides the most accurate assessment of oxygenation (PaO2) and ventilation (PaCO2) post-collision. Peak flow assesses asthma, pulse oximetry measures oxygen saturation only, and CT evaluates structure.
Which client event would be considered an adverse event and would require completion of an incident/event/irregular occurrence/variance report? Select all that apply.
- A. Administered 9.00 AM medication at 9.30 AM
- B. Developed worsening cellulitis after missing antibiotics for 1 day
- C. Has a seizure and a history of epilepsy
- D. Slides off the edge of the bed and ends up sitting on the floor
- E. Waits 4 hours to be transported for STAT diagnostic CT scan
Correct Answer: B,D,E
Rationale: Adverse events requiring an incident report include worsening cellulitis due to missed antibiotics , a fall even without injury , and a significant delay in a STAT procedure . Late medication administration is a variance but not typically an adverse event unless harm occurs, and a seizure in a known epileptic is expected unless protocol was not followed.
The doctor has ordered the insertion of an NG tube to determine the extent of gastric bleeding in a client with a gastric ulcer. To facilitate the insertion of the NG tube, the nurse should:
- A. Place the NG tube in warm water prior to insertion.
- B. Place the client in a supine position.
- C. Ask the client to swallow as the tube is advanced.
- D. Ask the client to hyper-extend his neck as the nurse begins to insert the tube.
Correct Answer: C
Rationale: Asking the client to swallow helps guide the NG tube into the esophagus and stomach, facilitating insertion.
The nurse is planning care for a client during the acute phase of a sickle cell vaso-occlusive crisis. Which of the following actions would be most appropriate?
- A. Fluid restriction 1000cc per day
- B. Ambulate in hallway 4 times a day
- C. Administer analgesic therapy as ordered
- D. Encourage increased caloric intake
Correct Answer: C
Rationale: Administer analgesic therapy as ordered. Pain management is critical during a sickle cell crisis.