Nokea
The nurse is caring for a client who had knee surgery this morning. Postoperative orders include a narcotic every three to four hours as needed for operative site pain and an ice bag. At 7:00 P.M., the client asks for pain medication. He was last medicated at 3:30 P.M. What is the best initial nursing action?
- A. Administer the prescribed analgesic
- B. Assess the location and nature of the pain
- C. Refill the ice bag as needed
- D. Reposition the client
Correct Answer: B
Rationale: Assessing pain location and nature ensures the medication is appropriate for operative site pain, guiding safe administration. Administering without assessment, refilling ice, or repositioning are premature.
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An 8-year-old client is returned to the recovery room after a bronchoscopy. The nurse should position the client
- A. in semi-Fowler's position.
- B. prone, with the head turned to the side.
- C. with the head of the bed elevated 45° and the neck extended.
- D. supine, with the head in the midline position.
Correct Answer: A
Rationale: Semi-Fowler’s position (30°–45° elevation) promotes lung expansion and reduces the risk of airway obstruction or aspiration post-bronchoscopy. Prone (B) limits respiratory assessment, neck extension (C) risks airway obstruction, and supine (D) is less optimal for breathing.
The nurse is caring for a client with a history of schizophrenia who is experiencing auditory hallucinations. Which of the following interventions is MOST appropriate?
- A. Argue with the client about the reality of the voices.
- B. Encourage the client to listen to music with headphones.
- C. Instruct the client to ignore the voices completely.
- D. Administer an antipsychotic medication as ordered.
Correct Answer: B
Rationale: Listening to music with headphones can distract from auditory hallucinations, reducing their intensity. Arguing (A) increases agitation, ignoring voices (C) is ineffective, and administering medication (D) is appropriate but not the most immediate non-pharmacologic intervention.
A client with retinal detachment of the right eye has a scleral buckling with instillation of silicone oil. Post-operatively the client should be positioned:
- A. In semi-Fowler's position with the head in neutral position
- B. Supine with the head turned to the right side
- C. In low Trendelenburg position with the head in neutral position
- D. Prone with the head turned to the left side
Correct Answer: D
Rationale: Following a scleral buckling with instillation of silicone oil or gas, the client should be positioned prone with the head turned so that the operative eye is facing upward. Answers A, B, and C would displace the oil and prevent it from enhancing a seal between the retina and choroid.
Marie is a 5-year-old girl is admitted with a diagnosis of Acute Lymphoblastic Leukemia.
Which of the following nursing interventions would be contraindicated to the patient with Leukemia?
- A. Take rectal temperature.
- B. Use soft toothbrush.
- C. Use normal saline for mouthwash TID.
- D. Avoid using dental floss.
Correct Answer: A
Rationale: Rectal temperatures risk rectal injury and infection in neutropenic patients.
The physician has ordered IV replacement of potassium for a patient with severe hypokalemia.
The nurse would administer the IV potassium
- A. by rapid bolus.
- B. diluted in 100 cc over 1 hour.
- C. diluted in 10 cc over 10 minutes.
- D. IV push.
Correct Answer: B
Rationale: Potassium is diluted and infused slowly to prevent cardiac arrhythmias.