Nokea
The nurse has provided self-care activity instructions to a client after the insertion of an internal cardioverter-defibrillator (ICD). The nurse determines that further instruction is needed if the client makes which statement?
- A. I need to avoid doing anything where there would be rough contact with the ICD insertion site.
- B. I can perform activities such as swimming, driving, or operating heavy equipment as I need to do them.
- C. I should try to avoid doing strenuous things that would make my heart rate go up to or above the rate cut-off on the ICD.
- D. I should keep away from electromagnetic sources such as transformers, large electrical generators, and metal detectors as well as running motors.
Correct Answer: B
Rationale: The client should avoid activities like swimming, driving, or operating heavy equipment until cleared by the healthcare provider, as these could pose risks related to the ICD function or sudden cardiac events. The other statements reflect appropriate self-care measures: avoiding rough contact protects the insertion site, avoiding strenuous activities prevents triggering the ICD, and avoiding electromagnetic sources minimizes interference with the device.
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The nurse is monitoring a male client with a spinal cord injury who is experiencing spinal shock. Which findings indicate that the spinal shock is resolving?
- A. Flaccidity
- B. Presence of a gag reflex
- C. Positive Babinski's reflex
- D. Development of hyperreflexia
- E. Return of the bulbocavernous reflex
- F. Return of reflex emptying of the bladder
Correct Answer: C,D,E,F
Rationale: Spinal shock is associated with acute injury to the spinal cord with temporary suppression of reflexes controlled by segments below the level of injury. It may last for 1 to 6 weeks. Indications that spinal shock is resolving include return of reflexes, development of hyperreflexia rather than flaccidity, and return of reflex emptying of the bladder. The return of the bulbocavernous reflex in male clients is also an early indicator of recovery from spinal shock. Babinski's reflex (dorsiflexion of the great toe with fanning of the other toes when the sole of the foot is stroked) is an early returning reflex. The gag reflex is not lost in spinal shock; therefore, its presence is not an indication of resolving spinal shock.
The nurse is caring for a client who has returned from the postanesthesia care unit after prostatectomy. The client has a three-way Foley catheter with an infusion of continuous bladder irrigation (CBI). Which color description of the urinary drainage should lead the nurse to determine that the flow rate is adequate?
- A. Dark cherry
- B. Clear as water
- C. Pale yellow or slightly pink
- D. Concentrated yellow with small clots
Correct Answer: C
Rationale: The infusion of bladder irrigant is not at a preset rate; rather, it is increased or decreased to maintain urine that is a clear, pale yellow color or has just a slight pink tinge. The infusion rate should be increased if the drainage is cherry colored or if clots are seen. Alternatively, the rate can be slowed down slightly if the returns are as clear as water.
A client has just taken a dose of trimethobenzamide. When the client states relief of which sign/symptom, is it appropriate for the nurse to determine that the medication has been effective?
- A. Nausea
- B. Heartburn
- C. Constipation
- D. Abdominal pain
Correct Answer: A
Rationale: Trimethobenzamide is an antiemetic agent that is used for the treatment of nausea and vomiting. The medication is not used to treat heartburn, constipation, or abdominal pain.
The nurse has given the client information about the use of sublingual nitroglycerin tablets prescribed for as-needed use if chest pain occurs. Which client statement helps assure the nurse that the client understands how to self-administer the medication?
- A. I will keep the nitroglycerin in a shirt pocket close to my body.
- B. I won't take the medication until the chest pain actually begins and intensifies.
- C. If I get a headache when I first start taking the nitroglycerin, then I will take an aspirin.
- D. I will discard unused nitroglycerin tablets 3 to 6 months after the bottle is opened, and obtain a new prescription.
Correct Answer: D
Rationale: Nitroglycerin may be self-administered sublingually 5 to 10 minutes before an activity that triggers chest pain. Tablets should be discarded 3 to 6 months after opening the bottle (per expiration date), and a new bottle of pills should be obtained from the pharmacy. Nitroglycerin is unstable and is affected by heat and cold, so it should not be kept close to the body (warmth) in a shirt pocket; rather, it should be kept in a jacket pocket or a purse. Headache often occurs with early use and diminishes in time. Acetaminophen may be used to treat headache.
The nurse has created a plan of care to include interventions focused on reassuming self-care for a client who is in traction. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?
- A. The client denies a need for assistance with care.
- B. The client allows the family to assist in the care.
- C. The client assists in self-care as much as possible.
- D. The client allows the nurse to complete the care on a daily basis.
Correct Answer: C
Rationale: A successful outcome for reassuming self-care is for the client to do as much of the self-care as possible. The nurse should promote independence in the client and allow the client to perform as much self-care as is optimal considering the client's condition. The nurse would determine that the outcome is unsuccessful if the client refuses care or allows others to perform the care.