Nokea
The nurse is admitting a client with acute appendicitis to the emergency department. The client has abdominal pain of 10 on a pain scale of 1 to 10. The client will be going to surgery as soon as possible. The nurse should:
- A. Contact the surgeon to request an order for a narcotic for the pain.
- B. Maintain the client in a recumbent position.
- C. Place the client on nothing-by-mouth (NPO) status.
- D. Apply heat to the abdomen in the area of the pain.
Correct Answer: C
Rationale: The client with acute appendicitis should be placed on NPO status in preparation for surgery to prevent aspiration risk. Narcotics may mask symptoms, a recumbent position is not specific, and heat could worsen inflammation. CN: Physiological adaptation; CL: Synthesize
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The client with peripheral vascular disease has been prescribed diltiazem (Cardizem). The nurse should determine the effectiveness of this medication by assessing the client for:
- A. Relief of anxiety
- B. Sedation
- C. Vasoconstriction
- D. Vasodilation
Correct Answer: D
Rationale: Diltiazem, a calcium channel blocker, promotes vasodilation in PVD, improving blood flow and reducing claudication symptoms. The nurse assesses for vasodilation (e.g., reduced pain, warmer extremities). It does not primarily relieve anxiety, cause sedation, or promote vasoconstriction.
The newly hired nurse cares for a client bitten by a venomous snake in the left hand. Which of the following interventions by the newly hired nurse requires follow-up by the charge nurse?
- A. Applying a tourniquet proximal to the bite.
- B. Removing the client's wristwatch and jewelry.
- C. Establishing intravenous (IV) access.
- D. Obtaining a type and crossmatch for fresh frozen plasma (FFP).
Correct Answer: A
Rationale: Applying a tourniquet can worsen tissue damage by restricting blood flow and concentrating venom, requiring follow-up. Removing jewelry (B) prevents constriction from swelling, establishing IV access (C) is essential for antivenom administration, and type and crossmatch (D) may be appropriate for potential complications.
A client post-cystoscopy is discharged. The nurse should instruct to:
- A. Resume normal activity.
- B. Avoid fluids for 24 hours.
- C. Expect blue urine.
- D. Take antibiotics for a week.
Correct Answer: A
Rationale: Normal activity can resume post-cystoscopy unless complications arise.
A client with chemotherapy-induced thrombocytopenia has a platelet count of 18,000/mm³. Which nursing intervention is most important?
- A. Administer aspirin for pain.
- B. Monitor for signs of bleeding.
- C. Encourage vigorous oral hygiene.
- D. Restrict visitors.
Correct Answer: B
Rationale: A platelet count of 18,000/mm³ indicates severe thrombocytopenia, making monitoring for bleeding (e.g., petechiae, epistaxis) the most important intervention to prevent complications.
A client with colon cancer had a left hemicolectomy 3 weeks previously. The client is still having difficulty maintaining an adequate oral intake to meet metabolic needs for optimal healing. Which of the following nutritional support methods would be most appropriate?
- A. Total parenteral nutrition through a central catheter.
- B. I.V. infusion of dextrose.
- C. Nasogastric feeding tube with protein supplement.
- D. Jejunostomy for high caloric feedings.
Correct Answer: C
Rationale: A nasogastric feeding tube with protein supplement is appropriate for short-term nutritional support post-hemicolectomy, as it delivers nutrients directly to the stomach while the client's oral intake improves.