Nokea
The nurse has attended a staff developmental conference on pediatric pain management. Which of the following statements by the nurse would indicate a correct understanding of the teaching?
- A. Patient-controlled analgesia (PCA) can be used as early as age 7.
- B. Lidocaine-adrenaline-tetracaine (LAT) can provide local anesthesia 2 hours after it is applied.
- C. Transdermal fentanyl patch can provide acute pain relief.
- D. Intramuscular delivery of pain medication is preferred for children.
Correct Answer: A
Rationale: PCA can be used in children as young as 7 if they understand the concept. LAT works within 30-60 minutes, fentanyl patches are for chronic pain, and IM injections are avoided in children due to pain and variability.
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A client with renal calculi has hematuria. The nurse should:
- A. Monitor urine output.
- B. Notify the physician immediately.
- C. Restrict fluids.
- D. Apply ice to the flank.
Correct Answer: A
Rationale: Hematuria is expected with renal calculi; monitoring ensures no excessive bleeding.
The client is ready for discharge after surgery for a deviated septum. Which of the following discharge instructions would be appropriate?
- A. Avoid activities that elicit Valsalva's maneuver.
- B. Take aspirin to control nasal discomfort.
- C. Avoid brushing the teeth until the nasal packing is removed.
- D. Apply heat to the nasal area to control swelling.
Correct Answer: A
Rationale: Avoiding Valsalva's maneuver (e.g., straining, heavy lifting) prevents increased pressure that could cause bleeding or disrupt the surgical site.
What should the nurse do first for a client with a suspected spinal cord injury?
- A. Immobilize the spine.
- B. Administer pain medication.
- C. Check motor function.
- D. Obtain a CT scan.
Correct Answer: A
Rationale: Immobilizing the spine is the first priority to prevent further injury in a suspected spinal cord injury.
A client who had an esophageal hernia repair 4 hours ago has a pulse rate of 90 bpm, respiration rate of 16/minute, blood pressure of 130/80 mm Hg, pulse oximeter of 91, and a temperature of 100.4°F (38°C). What should the nurse do first?
- A. Obtain a culture of the incision.
- B. Notify the surgeon to obtain an antibiotic order.
- C. Adjust the client to a sitting position to take deep breaths.
- D. Administer an antipyretic medication.
Correct Answer: C
Rationale: A pulse oximetry of 91 indicates mild hypoxemia. Adjusting to a sitting position and encouraging deep breaths improves oxygenation, addressing the most immediate concern.
Appropriate nursing diagnoses for a client with hypothyroidism would include which of the following?
- A. Risk for injury (corneal abrasion) related to incomplete closure of the eyelid.
- B. Imbalanced nutrition: Less than body requirements related to hypermetabolism.
- C. A clinical evidence related to diarrhea.
- D. Activity intolerance related to fatigue associated with the disorder.
Correct Answer: D
Rationale: Hypothyroidism causes fatigue due to slowed metabolism, making activity intolerance a relevant nursing diagnosis. The other options are more associated with hyperthyroidism or unrelated conditions.