Nokea
The nurse is assessing a client who had surgery 12 hours ago and is receiving IV morphine for incisional pain. It would require immediate follow-up if the client
- A. Has a blood pressure of 106/68 mm Hg
- B. Falls asleep while speaking with the nurse
- C. Reports burning at the IV site during administration of the medication
- D. Reports dizziness when getting out of bed to use the bathroom
Correct Answer: C
Rationale: Burning at the IV site suggests possible extravasation or phlebitis, which can lead to tissue damage or infection, requiring immediate intervention. Low blood pressure, falling asleep, and dizziness are less urgent and can be associated with morphine's expected effects.
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The nurse is caring for a client with a feeding tube that has become obstructed. Which intervention should the nurse implement first to unclog the tube?
- A. Flush and aspirate the tube with warm water
- B. Instill a digestive enzyme solution into the tube
- C. Instill cola or cranberry juice into the tube
- D. Use a small barrel syringe to flush the tube
Correct Answer: A
Rationale: Flushing with warm water is the first, safest step to unclog a feeding tube. Enzymes or other solutions are used if water fails, and small syringes may cause excessive pressure.
The nurse is performing an assessment on a child with severe airway obstruction. Which finding would the nurse anticipate?
- A. Retractions in the intercostal tissues of the thorax
- B. Chest pain aggravated by respiratory movement
- C. Cyanosis and mottling of the skin
- D. Rapid, shallow respirations
Correct Answer: A
Rationale: Retractions in the intercostal tissues of the thorax. Severe airway obstruction causes extreme intercostal retractions due to increased respiratory effort.
The charge nurse on the eating disorder unit instructs a new staff member to weigh each client in his or her hospital gown only. What is the rationale for this nursing intervention?
- A. To reduce the risk of the client feeling cold due to decreased fat and subcutaneous tissue
- B. To cover the bony prominence and areas where there is skin breakdown
- C. The client knows what type of clothing to wear when weighed
- D. To reduce the tendency of the client to hide objects under his or her clothing
Correct Answer: D
Rationale: To reduce the tendency of the client to hide objects under his or her clothing. Clients may conceal weights to falsely indicate weight gain.
What must the nurse emphasize when teaching a client with depression about a new prescription for nortriptyline (Pamelor)?
- A. Symptom relief occurs in a few days
- B. Alcohol use is to be avoided
- C. Medication must be stored in the refrigerator
- D. Episodes of diarrhea can be expected
Correct Answer: B
Rationale: Alcohol potentiates the action of tricyclic antidepressants.
The nurse is reinforcing teaching with the parents of a 6-year-old client who is experiencing fecal incontinence related to functional constipation. Which of the following information should the nurse reinforce? Select all that apply.
- A. Instruct your child to sit on the toilet for 30 minutes after each meal.
- B. Use a reward system, such as a sticker chart, to encourage your child.
- C. Provide your child with a foot stool to rest the feet on while sitting on the toilet.
- D. Encourage your child to increase the intake of fluids throughout the day to soften the stool.
- E. Keep a record of your child's bowel movements, laxative use, and episodes of incontinence
Correct Answer: B,C,D,E
Rationale: Reward systems, foot stools, increased fluids, and tracking bowel movements aid in managing constipation. Sitting for 30 minutes is excessive and impractical.