Nokea
The nurse is caring for a 12 year-old with an acute illness. Which of the following indicates the nurse understands common sibling reactions to hospitalization?
- A. Younger siblings adapt very well
- B. Visitation is helpful for both
- C. The siblings may enjoy privacy
- D. Those cared for at home cope better
Correct Answer: B
Rationale: Visitation is helpful for both. Contact with the ill child helps siblings understand hospitalization and maintain relationships.
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A client who is 2 days post-operative from an appendectomy requests medication for pain. The client's vital signs are as follows: pulse 96, respirations 30, BP 130/92. The nurse should:
- A. Ask whether the client is anxious.
- B. Give the pain medication.
- C. Check the dressing for bleeding.
- D. Recheck the client's vital signs.
Correct Answer: B
Rationale: Pain medication is appropriate for a post-op client with pain and stable vitals. Anxiety may contribute, but pain should be addressed first. Bleeding checks or rechecking vitals are unnecessary without specific indicators.
A client is admitted with a diagnosis of myocardial infarction (MI). The client is complaining of chest pain. The nurse knows that pain related to an MI is due to
- A. Insufficient oxygenation of the cardiac muscle
- B. Potential circulatory overload
- C. Left ventricular overload
- D. Electrolyte imbalance
Correct Answer: A
Rationale: Insufficient oxygenation of the cardiac muscle. Due to ischemia of the heart muscle, the client experiences pain. This happens because an MI can block or interfere with the normal cardiac circulation.
Laboratory Reference Ranges
Sodium
136-145 mEq/L
(136-145 mmol/L)
The medical-surgical nurse cares for a group of clients. Which client situations would prompt the nurse to notify the health care provider during the middle of the night? Select all that apply.
- A. Client develops right-sided upper and lower extremity drift
- B. Client found lying unconscious on the floor
- C. Client has order for heparin with surgery planned for the morning
- D. Client has serum sodium of 124 mEq/L (124 mmol/L)
- E. Client refuses a prescribed, routine pain medication
Correct Answer: A,B,C,D
Rationale: Extremity drift (A), unconsciousness (B), heparin before surgery (C), and severe hyponatremia (D) are urgent and require notification. Refusing pain medication (E) is not critical.
An adult has been taking captopril (Capoten) for hypertension. The client tells the nurse that he has a dry cough and sometimes gets dizzy when he stands up. What conclusions should the nurse make regarding this client?
- A. The client is having severe side effects and should discontinue the drug until after he sees his physician.
- B. Dizziness is a common side effect of antihypertensives. The cough is probably unrelated to the medication.
- C. A dry cough is a common side effect of angiotensin-converting enzyme (ACE) inhibitors. The client should stand up slowly to avoid orthostatic hypotension, a common side effect of antihypertensives.
- D. Cough is a serious side effect and usually results in discontinuing the medication. The dizziness will get better with time.
Correct Answer: C
Rationale: Dry cough and orthostatic hypotension are common ACE inhibitor side effects; slow position changes mitigate dizziness, and cough may require evaluation.
The morning weight for a client with emphysema indicates that the client has gained 5 pounds in less than a week, even though his oral intake has been modest. The client's weight gain may reflect which associated complication of COPD?
- A. Polycythemia
- B. Cor pulmonale
- C. Left ventricular failure
- D. Compensated acidosis
Correct Answer: B
Rationale: Rapid weight gain in a client with emphysema, despite modest intake, suggests fluid retention, which is commonly associated with cor pulmonale, a complication of COPD involving right heart failure due to lung disease. Answer A (polycythemia) is a blood disorder, not directly linked to weight gain. Answer C (left ventricular failure) is less likely in COPD compared to cor pulmonale. Answer D (compensated acidosis) does not cause weight gain.