Nokea
The nurse is caring for a client diagnosed with Reye's syndrome. The nurse understands that this illness is caused by which medication?
- A. Ibuprofen
- B. Aspirin
- C. Acetaminophen
- D. Diphenhydramine
Correct Answer: B
Rationale: Reye's syndrome is associated with aspirin use, particularly in children with viral infections, leading to liver and brain complications.
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A 45-year-old client had a complete abdominal hysterectomy with bilateral salpingo-oophorectomy 2 days ago. The client's abdominal dressing is dry and intact. In addition, the client is taking liquids and voiding a sufficient quantity of straw-colored urine. While sitting up in the chair after her bath, the client complains of severe pain and numbness in her left leg. The nurse should respond immediately by:
- A. Administering pain medication
- B. Assessing for edema in the left leg
- C. Assessing color and temperature of the left leg
- D. Encouraging the client to change her position
Correct Answer: C
Rationale: Severe pain and numbness post-hysterectomy suggest possible deep vein thrombosis (DVT) or arterial occlusion, common postoperative complications. Assessing color and temperature of the leg (e.g., pallor, coolness) helps identify circulatory compromise. Pain medication, edema assessment, or position change are less urgent.
The nurse receives a prescription from the primary healthcare provider (PHCP) for metoprolol 5 mL intravenous (IV) push x 1 dose. The nurse should take which priority action before administering the medication?
- A. Clarify the prescription with the primary healthcare provider (PHCP)
- B. Assess vital signs
- C. Review the prescription with the pharmacist
- D. Assess the client's allergies
Correct Answer: A
Rationale: Metoprolol IV push prescriptions require clarification to ensure correct dosage and administration rate.
What would be the nurse's best response to the client's expressed feelings of isolation as a result of having hepatitis?
- A. Don't worry. It's normal to feel that way.'
- B. Your friends are probably afraid of contracting hepatitis from you.'
- C. I'm sure you're imagining that!'
- D. Tell me more about your feelings of isolation.'
Correct Answer: D
Rationale: Encouraging the client to express feelings (D) promotes therapeutic communication and understanding. Dismissing feelings (A, C) or assuming others' fears (B) is non-therapeutic.
The nurse should teach the client with Addison's disease that the adverse effect of bronze-colored skin is thought to be caused by which of the following?
- A. Hypersensitivity to sun exposure.
- B. Increased serum bilirubin level.
- C. Adverse effects of the glucocorticoid therapy.
- D. Increased secretion of adrenocorticotropic hormone (ACTH).
Correct Answer: D
Rationale: Bronze-colored skin in Addison's disease results from increased ACTH, which stimulates melanin production.
The nurse manager on the orthopedic unit is reviewing a report that indicates that in the last month five clients were diagnosed with pressure ulcers. The nurse manager should:
- A. Use benchmarking procedures to compare the findings with other nursing units in the hospital.
- B. Ask the staff education department to conduct an educational session about preventing pressure ulcers.
- C. Institute a quality improvement plan that identifies contributing factors, proposes solutions, and sets improvement outcomes.
- D. Conduct a chart audit to determine which nurses on which shifts were giving nursing care to the clients with pressure ulcers.
Correct Answer: C
Rationale: A quality improvement plan addresses root causes, proposes solutions, and sets measurable outcomes, effectively reducing pressure ulcer incidence.