Nokea
The nurse is caring for a client at 21 weeks gestation with reports of occasional, bothersome heartburn (pyrosis). Which of the following lifestyle changes should the nurse recommend? Select all that apply.
- A. Avoid intake of dairy products
- B. Drink large amounts of fluid with meals
- C. Eat several small meals each day
- D. Eliminate fried, fatty foods
- E. Lie down on the left side after meals
Correct Answer: C,D
Rationale: Small, frequent meals reduce stomach acid reflux, and avoiding fatty foods decreases acid production. Dairy can neutralize acid, large fluid intake with meals distends the stomach, and lying down post-meal worsens reflux.
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A client reports 7 of 10 on the pain scale at 2300 and asks if it is too soon to receive 'another pain pill.' The nurse reviews the medication administration record. Which intervention should the nurse implement?
- A. Administer the hydrocodone/acetaminophen as prescribed
- B. Call the health care provider to request a prescription for a different analgesic
- C. Decrease the dose of hydrocodone/acetaminophen from 2 tablets to 1
- D. Prepare to administer naloxone
Correct Answer: A
Rationale: Pain rated 7/10 warrants administration of the prescribed analgesic if within the dosing interval. No indications suggest overdose (naloxone) or need for a different medication. Reducing the dose may inadequately manage pain.
Continuous bladder irrigation is prescribed for an adult who had bladder surgery; 1000 mL of irrigating solution was instilled in the last eight hours. The amount of drainage in the urine drainage bag for the last eight hours is 1700 mL. How much is the client's urine output for the last eight hours?
- A. 270 mL
- B. 700 mL
- C. 1700 mL
- D. 2799 mL
Correct Answer: B
Rationale: Urine output is calculated by subtracting instilled irrigation fluid (1000 mL) from total drainage (1700 mL), yielding 700 mL of actual urine.
The unit secretary notifies the nurse that 4 clients called the nurses' station reporting pain. Which client should the nurse assess first?
- A. Client who had a foot amputation today reporting left shoulder pain radiating down the arm
- B. Client who has acute pancreatitis reporting severe, continuous, penetrating abdominal pain
- C. Client who has multiple myeloma reporting deep pelvic pain after walking down the hall
- D. Client who has sickle cell disease reporting severe pain in the arms and upper back
Correct Answer: A
Rationale: Shoulder pain radiating down the arm post-amputation suggests a possible cardiac event (e.g., angina), a life-threatening condition requiring immediate assessment. Other pains, while severe, are more likely related to known conditions.
The practical nurse is assisting the registered nurse in creating a care plan for a client who is intubated, on mechanical ventilation, and receiving continuous enteral tube feedings via a small-bore nasogastric tube. Which interventions should be included to prevent aspiration in this client? Select all that apply.
- A. Check gastric residual every 12 hours
- B. Keep head of the bed at ≥30 degrees
- C. Maintain endotracheal cuff pressure
- D. Monitor for abdominal distension every 4 hours
- E. Use caution when administering sedatives
Correct Answer: B,C,D,E
Rationale: Elevating the head of the bed (≥30 degrees) reduces reflux, proper cuff pressure seals the airway, monitoring distension detects feed intolerance, and cautious sedation prevents respiratory depression. Residual checks every 4-6 hours are standard, not 12.
The nurse is caring for a client who just had a total thyroidectomy. Which finding does the nurse recognize as most important to report immediately?
- A. Elevated blood pressure
- B. Heart rate irregularity
- C. Low oxygen saturation
- D. Noisy breathing
Correct Answer: D
Rationale: Noisy breathing post-thyroidectomy may indicate airway obstruction from hematoma or edema, a life-threatening emergency. Other findings are less immediately critical but still require monitoring.