Nokea
The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
- A. At home I take my pills at 8:00 am.
- B. It costs a lot of money to buy all of these pills.
- C. I get so tired of taking pills every day.
- D. This is a new pill I have never taken before.
Correct Answer: D
Rationale: The client's statement that 'This is a new pill I have never taken before' indicates the need for further assessment by the nurse to ensure the medication is correct and safe. Choices A, B, and C do not raise immediate concerns about the medication order; therefore, they are incorrect. Choice A simply provides information about the client's usual medication schedule, choice B is related to the cost of the pills, and choice C expresses fatigue from taking pills, but none of these statements suggest a potential issue with the new medication.
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A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
- A. Give analgesics on an around-the-clock schedule for pain management.
- B. Administer analgesic medication only when the pain becomes severe.
- C. Provide medication to keep the client comfortable without inducing sedation.
- D. Allow brief medication-free periods to promote comfort during daily activities.
Correct Answer: A
Rationale: The most effective pain management strategy in hospice care involves administering analgesics on an around-the-clock schedule (A) to maintain pain control. Waiting until pain is severe before administering medication (B) is not ideal as it may lead to inadequate pain relief. While providing comfort is crucial in hospice care, sedation that prevents the client from interacting and experiencing their remaining time should be minimized. Therefore, keeping the client comfortable without excessive sedation (C) is preferred. Allowing for some periods without medication (D) may be appropriate but should not compromise the client's comfort and pain control.
Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?
- A. Sensory pattern, area, intensity, and nature of the pain.
- B. Identification of trigger points through palpation and manual pressure on painful areas.
- C. Current schedule and total dosages of medications used for breakthrough pain.
- D. Assessment of sympathetic responses indicative of acute pain onset.
Correct Answer: A
Rationale: The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.
When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?
- A. Position the client supine for a few minutes
- B. Assist the client to stand at the bedside
- C. Apply the blood pressure cuff securely
- D. Record the client's pulse rate and rhythm
Correct Answer: A
Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.
A client with a diagnosis of asthma is receiving albuterol (Proventil) via a metered-dose inhaler (MDI). Which assessment finding indicates that the medication is effective?
- A. Increased oxygen saturation.
- B. Decreased respiratory rate.
- C. Absence of audible wheezing.
- D. Improved exercise tolerance.
Correct Answer: A
Rationale: Increased oxygen saturation (A) is the most direct indicator of the effectiveness of albuterol (Proventil) in improving breathing. Oxygen saturation reflects the amount of oxygen in the blood, showing that the albuterol is helping with air exchange in the lungs. While decreased respiratory rate (B), absence of audible wheezing (C), and improved exercise tolerance (D) are positive outcomes, they are secondary to oxygen saturation. Oxygen saturation directly reflects the improvement in the client's respiratory status and the effectiveness of the medication.
After hemodialysis, a client with a history of chronic renal failure has just returned to the unit. What is the most important assessment for the nurse to make?
- A. Auscultate the client's lung sounds.
- B. Assess the client's blood pressure.
- C. Monitor the client's weight.
- D. Check the client's fistula for bruit and thrill.
Correct Answer: D
Rationale: The most crucial assessment for the nurse to make after hemodialysis in a client with chronic renal failure is to check the client's fistula for bruit and thrill (D). This assessment is essential to ensure the patency of the fistula and adequate blood flow. Auscultating lung sounds (A), assessing blood pressure (B), and monitoring weight (C) are important assessments but are secondary to evaluating the fistula. Checking the fistula is vital as it directly impacts the effectiveness of the client's dialysis treatment and the patency of the vascular access, ensuring successful dialysis sessions.