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The nurse is assessing the leg pain of a client who has just undergone right femoral-popliteal artery bypass grafting. Which question would be most useful in determining whether the client is experiencing graft occlusion?
- A. Can you describe what the pain feels like?
- B. Can you rate the pain on a scale of 1 to 10 ?
- C. Did you get any relief from the last dose of pain medication?
- D. Can you compare this pain to the pain you felt before surgery?
Correct Answer: D
Rationale: The most frequent indication that a graft is occluding is the return of pain that is similar to that experienced preoperatively. Standard pain assessment techniques also include the items described in the remaining options, but these will not help differentiate current pain from preoperative pain.
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While assisting the physician with an amniocentesis on a multigravid client at 38 weeks' gestation, the nurse observes that the fluid is very cloudy and thick. The nurse interprets this finding as indicating which of the following?
- A. Intrauterine infection.
- B. Fetal meconium staining.
- C. Erythroblastosis fetalis.
- D. Normal amniotic fluid.
Correct Answer: B
Rationale: Cloudy, thick amniotic fluid often indicates meconium staining, suggesting fetal distress, which requires further evaluation.
The nursing staff has safely and successfully secluded and restrained a client with acute mania who discussed the nurse and threw a chair against the wall in the community room. Which statement by the nurse is most helpful to the client at this time?
- A. Threatening others and throwing furniture is not allowed.'
- B. You have been restrained until you can manage your behavior.'
- C. Since you have been here before, you know what the rules are.'
- D. We are only doing this for your own good, so calm down.'
Correct Answer: B
Rationale: Explaining the reason for restraint (to ensure safety until behavior is managed) is therapeutic, clear, and nonjudgmental, helping the client understand the intervention.
The nurse is conducting health assessments for school-age children. A characteristic behavior of a 7-year-old girl is that she:
- A. Likes to play only with other girls.
- B. Prefers to play with her sister.
- C. Prefers to play team games.
- D. Likes to play alone.
Correct Answer: C
Rationale: At 7 years, children typically enjoy social interaction and team games, reflecting their developmental stage of cooperative play.
A client has received electroconvulsive therapy (ECT). What intervention should the nurse perform first in the posttreatment area and upon the client's awakening?
- A. Assist the client from the stretcher to a wheelchair.
- B. Orient the client and monitor his or her vital signs.
- C. Offer the client frequent reassurance and repeat orientation statements.
- D. Assess for a gag reflex so that the client can eat and drink with safety.
Correct Answer: B
Rationale: The nurse should first monitor vital signs, orient the client, and review with the client that he or she just received an ECT treatment. The posttreatment area should include accessibility to the anesthesia staff, oxygen, suction, pulse oximeter, vital sign monitoring, and emergency equipment. The nursing interventions outlined in the remaining options will follow accordingly.
A client has been given a prescription to begin using nitroglycerin transdermal patches. The nurse instructs the client about this medication administration system and tells the client to expect which side effect?
- A. Sweating
- B. Headache
- C. Dry mouth
- D. Constipation
Correct Answer: B
Rationale: Nitroglycerin is a coronary vasodilator used in the management of coronary artery disease. A common side effect of this medication is an intense headache. Clients should be instructed about this side effect and that acetaminophen can be helpful in alleviating discomfort. The remaining options are not associated with the use of this medication.