Nokea
The nurse is caring for a client receiving hydromorphone via patient-controlled analgesia (PCA). The nurse should prioritize assessing the client's
- A. blood pressure.
- B. pain level.
- C. activity tolerance.
- D. bowel patterns.
Correct Answer: B
Rationale: Pain level is the priority assessment for a client on PCA with hydromorphone to ensure effective pain management and adjust dosing if needed.
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A client has a chest tube attached to a waterseal drainage system and the nurse notes that the fluid in the chest tube and in the water-seal column has stopped fluctuating. The nurse should determine:
- A. The lung has fully expanded.
- B. The lung has collapsed.
- C. The chest tube is in the pleural space.
- D. The mediastinal space has decreased.
Correct Answer: A
Rationale: Lack of fluctuation in the water-seal column suggests the lung has fully expanded, resolving the pneumothorax. Collapsed lung, tube placement, or mediastinal changes would show other signs.
A nursing assistant is providing care to a client with left-sided paralysis. Which of the following actions by the nursing assistant requires the nurse to provide further instruction?
- A. Providing passive range of motion exercises to the left extremities during the bed bath.
- B. Elevating the foot of the bed to reduce edema.
- C. Pulling up the client under the left shoulder when getting out of bed to a chair.
- D. Putting high top tennis shoes on the client after bathing.
Correct Answer: C
Rationale: Pulling under the paralyzed shoulder can cause injury or discomfort. Passive ROM, elevating the bed, and high-top shoes are appropriate for paralysis care.
A 25-year-old client taking hydroxychloroquine (Plaquenil) for rheumatoid arthritis reports difficulty seeing out of her left eye. Correct interpretation of this assessment finding indicates which of the following?
- A. Development of a cataract.
- B. Possible retinal degeneration.
- C. Part of the disease process.
- D. A coincidental occurrence.
Correct Answer: B
Rationale: Hydroxychloroquine can cause retinal toxicity, leading to vision changes. This is a known side effect requiring immediate medical evaluation.
The nurse is teaching a diabetic client using an empowerment approach. The nurse should initiate teaching by asking which of the following?
- A. How much does your family need to be involved in learning about your condition?'
- B. What is required for your family to manage your symptoms?'
- C. What activities are most important for you to be able to maintain control of your diabetes?'
- D. What do you know about your medications and condition?'
Correct Answer: D
Rationale: An empowerment approach focuses on the client's knowledge and needs. Starting with what the client already knows about their condition and medications helps tailor education effectively.
Which of the following adverse effects would the nurse expect the client to exhibit in the event of too rapid an infusion of TPN solution?
- A. Negative nitrogen balance.
- B. Circulatory overload.
- C. Hypoglycemia.
- D. Hypokalemia.
Correct Answer: B
Rationale: Too rapid an infusion of TPN can cause circulatory overload due to the high volume and osmolarity of the solution. Negative nitrogen balance, hypoglycemia, or hypokalemia are not directly caused by rapid infusion. CN: Pharmacological and parenteral therapies; CL: Analyze