Nokea
The nurse is assessing a client for neurologic impairment after a total hip replacement. Which of the following would indicate impairment in the affected extremity?
- A. Decreased distal pulse.
- B. Inability to move.
- C. Diminished capillary refill.
- D. Coolness to the touch.
Correct Answer: B
Rationale: Inability to move suggests nerve damage, a serious complication requiring immediate evaluation.
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A client receiving chemotherapy for metastatic colorectal cancer has had 2 days of vomiting. Assessment findings include: irregular pulse of 120, blood pressure 88/48, respiratory rate of 14, serum potassium of 2.9 mEq/L, and arterial blood gas€”pH 7.46, PCO‚‚ 45, PO‚‚ 95, bicarbonate level 29 mEq/L. Which of the following interventions is appropriate for the nurse to administer to the client?
- A. Oxygen at 4 L per nasal cannula.
- B. Potassium 40 mEq PO now.
- C. 5% Dextrose in 0.45% Normal Saline with KCl 40 mEq/L at 125 mL/hour.
- D. NaHCO‚ƒ 75 mEq IV.
Correct Answer: C
Rationale: Hypokalemia (2.9 mEq/L) and hypotension (88/48) due to vomiting require I.V. fluid and potassium replacement (D5 0.45% NS with KCl) to correct electrolyte imbalance and dehydration. The alkalosis (pH 7.46) does not require bicarbonate, and oral potassium is unsafe with vomiting.
The client with a major burn injury receives total parenteral nutrition (TPN). The expected outcome is to:
- A. Correct water and electrolyte imbalances.
- B. Allow the gastrointestinal tract to rest.
- C. Provide supplemental vitamins and minerals.
- D. Ensure adequate caloric and protein intake.
Correct Answer: D
Rationale: Major burn injuries significantly increase metabolic demands, requiring high caloric and protein intake to support healing and tissue repair. TPN is primarily used to meet these nutritional needs when oral or enteral feeding is not feasible.
The client with rheumatoid arthritis tells the nurse, 'I have a friend who took gold shots and had a wonderful response. Why didn't my physician let me try that?' Which of the following responses by the nurse would be most appropriate?
- A. It's the physician's prerogative to decide how to treat you. The physician has chosen what is best for your situation.'
- B. Tell me more about your friend's arthritic condition. Maybe I can answer that question for you.'
- C. That drug is used for cases that are worse than yours. It wouldn't help you, so don't worry about it.'
- D. Every person is different. What works for one client may not always be effective for another.'
Correct Answer: D
Rationale: Individual responses to treatments vary due to differences in disease severity, comorbidities, and side effect profiles. This response educates the client without dismissing their concerns.
Which of the following client statements identifies a knowledge deficit about cast care?
- A. I'll elevate the cast above my heart initially.'
- B. I'll exercise my joints above and below the cast.'
- C. I can pull out cast padding to scratch inside the cast.'
- D. I'll apply ice for 10 minutes to control edema for the first 24 hours.'
Correct Answer: C
Rationale: Pulling out cast padding can cause skin irritation or pressure sores, indicating a knowledge deficit.
The nurse explains to the client that the main reason a back rub is used as therapy to relieve pain is because the massage:
- A. Blocks pain impulses from the spinal cord to the brain.
- B. Blocks pain impulses from the brain to the spinal cord.
- C. Stimulates the release of endorphins.
- D. Distracts the client's focus on the source of the pain.
Correct Answer: C
Rationale: Massage, like a back rub, stimulates endorphin release, which naturally reduces pain perception. It does not block pain impulses directly or act solely as a distraction.