Nokea
The nurse interviews a 22-year-old female client who is scheduled for abdominal surgery the following week. The client is obese and uses estrogen-based oral contraceptives. This client is at high risk for development of:
- A. Atherosclerosis
- B. Diabetes
- C. Vasospastic disorder (Raynaud's disease)
- D. Thrombophlebitis
Correct Answer: D
Rationale: Obesity and estrogen-based oral contraceptives increase the risk of thrombophlebitis by promoting hypercoagulability and venous stasis, especially during surgery. Atherosclerosis, diabetes, and Raynaud's are less directly related to these risk factors.
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The nurse is assessing a client for movement after halo traction placement for a C8 fracture. The nurse should document which of the following?
- A. The client's shoulders shrug against downward pressure of the examiner's hands.
- B. The client's arm pulls up from a resting position against resistance.
- C. The client's arm straightens out from a flexed position against resistance.
- D. The client's hand-grasp strength is equal.
Correct Answer: A
Rationale: A C8 fracture affects the lower cervical nerves, but shoulder shrug (trapezius, innervated by cranial nerve XI and C3-C4) should remain intact. Arm movements and hand grasp involve C5-C8 and may be impaired, making shoulder shrug the most reliable intact movement to document.
A 20-year-old who hit his head while playing football has a tonic-clonic seizure. Upon awakening from the seizure, the client asks the nurse, "What caused me to have a seizure? I've never had one before." Which cause should the nurse include in the response as a primary cause of tonic-clonic seizures in adults older than age 20?
- A. Head trauma.
- B. Electrolyte imbalance.
- C. Congenital defect.
- D. Epilepsy.
Correct Answer: A
Rationale: Head trauma is a primary cause of seizures in adults over 20, especially in the context of a recent injury. Electrolyte imbalances, congenital defects, or epilepsy are less likely without additional history.
A client is eligible for patient-controlled analgesia (PCA) when:
- A. A family member is able to assist with self-dosing.
- B. There is a court-appointed advocate to assist with self-dosing.
- C. The client has the ability to self-dose.
- D. There is a nurse to assist with self-dosing.
Correct Answer: C
Rationale: PCA requires the client to have the cognitive and physical ability to self-dose, ensuring safe and effective pain management.
A client has renal colic due to renal lithiasis. What is the nurse's first priority in managing care for this client?
- A. I need to know the client to ingest fluids.
- B. Encourage the client to drink at least 500 mL of water each hour.
- C. Request the central supply department to send supplies for straining urine.
- D. Administer an opioid analgesic as prescribed.
Correct Answer: D
Rationale: Severe pain from renal colic is the priority, requiring opioid analgesics for immediate relief to improve client comfort and cooperation.
The nurse is preparing a staff education program about medication reconciliation. Which of the following information should the nurse include? Select all that apply.
- A. Discontinued medications should be included while performing medication reconciliation.
- B. Medications taken on an as-needed basis can be excluded from this process.
- C. New medication orders should be compared with the current list.
- D. Medication reconciliation should be performed after the client has been discharged.
- E. Over-the-counter (OTC) medications should be included in the medication reconciliation.
Correct Answer: A,C,E
Rationale: Medication reconciliation includes discontinued medications, new orders, and OTC medications to ensure a complete and accurate list; it should occur at admission, transfer, and discharge, and PRN medications should not be excluded.