Nokea
The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:
- A. Take the blood pressure, pulse, and temperature
- B. Ask the client to rate his pain on a scale of 0-5
- C. Watch the client's facial expression
- D. Ask the client if he is in pain
Correct Answer: B
Rationale: A pain scale provides a reliable, subjective measure of pain.
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A 3-year-old is immobilized in a hip spica cast. Which discharge instruction should be given to the parents?
- A. Keep the bed flat, with a small pillow beneath the cast.
- B. Provide crayons and a coloring book for play activity.
- C. Increase her intake of high-calorie foods for healing.
- D. Tuck a disposable diaper beneath the cast at the perineal opening.
Correct Answer: D
Rationale: Tucking a diaper beneath the cast at the perineal opening helps keep the cast clean and prevents skin irritation.
The first action that the nurse should take if she finds the client has an O2 saturation of 68% is:
- A. Elevate the head
- B. Recheck the O2 saturation in 30 minutes
- C. Apply oxygen by mask
- D. Assess the heart rate
Correct Answer: C
Rationale: An O2 saturation of 68% indicates severe hypoxemia, requiring immediate oxygen administration.
What is the critical point for PO2 (the 'ICU' point), the percentage point at which there is marked decrease in oxygen saturation? Record your answer using a whole number.
Correct Answer: 90
Rationale: The critical PO2 point is around 90 mmHg, where oxygen saturation drops significantly, often requiring ICU intervention.
The client with preeclampsia is admitted to the unit with an order for magnesium sulfate IV. Which action by the nurse indicates a lack of understanding of magnesium sulfate?
- A. The nurse places a sign over the bed not to check blood pressures in the left arm.
- B. The nurse obtains an IV controller.
- C. The nurse inserts a Foley catheter.
- D. The nurse darkens the room.
Correct Answer: A
Rationale: Avoiding blood pressure checks in one arm is unrelated to magnesium sulfate; the other actions align with monitoring and managing side effects.
The client is admitted to the unit after a cholescystectomy. Montgomery straps are utilized with this client. The nurse is aware that Montgomery straps are utilized on this client because:
- A. The client is at risk for evisceration
- B. The client will require frequent dressing changes
- C. The straps provide support for drains that are inserted into the incision
- D. No sutures or clips are used to secure the incision
Correct Answer: B
Rationale: Montgomery straps are used to secure dressings in a way that allows for frequent changes without removing adhesive, which is common after a cholecystectomy due to drainage or wound care needs.