Nokea
The nurse is caring for a client who has just undergone a colectomy. Which of the following interventions is most important in the immediate postoperative period?
- A. Monitor for signs of bowel perforation.
- B. Encourage early ambulation.
- C. Administer oral fluids immediately.
- D. Keep the client on bed rest for 48 hours.
Correct Answer: B
Rationale: Encouraging early ambulation post-colectomy prevents complications like ileus and deep vein thrombosis.
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A client is experiencing symptoms of early alcohol withdrawal. The client's blood pressure is 150/85 mm Hg and the pulse is 98 bpm. The nurse should:
- A. Administer lorazepam (Ativan).
- B. Apply arm and leg restraints.
- C. Assign an unlicensed assistive personnel to sit with the client.
- D. Notify the physician.
Correct Answer: D
Rationale: Notifying the physician is the priority to obtain orders for managing alcohol withdrawal symptoms, which may require medications like lorazepam.
The nurse recognizes that a client with pain disorder is improving when the client says which of the following?
- A. I need to have a good cry about all the pain I've been in and then not dwell on it.'
- B. I need to find another physician who can accurately diagnose my condition.'
- C. The pain medicine that you gave me helps me to relax.'
- D. I'm angry with all of the doctors I've seen who don't know what they're doing.'
Correct Answer: A
Rationale: Expressing a desire to process emotions and move forward indicates improved coping, a sign of progress in managing pain disorder.
The nurse is caring for a client with a diagnosis of deep vein thrombosis (DVT). Which of the following interventions is most appropriate?
- A. Applying cold packs to the affected leg.
- B. Encouraging ambulation every hour.
- C. Administering heparin as ordered.
- D. Elevating the leg above heart level.
Correct Answer: C,D
Rationale: Heparin prevents clot extension in DVT, and elevating the leg reduces swelling and promotes venous return.
A client has been taking imipramine [Tofranil] for his depression for 2 days. His sister asks the nurse, 'Why is he still so depressed?' Which of the following responses by the nurse is most appropriate?
- A. Your brother is experiencing a very serious depression.
- B. I'll be sure to convey your concern to his physician.
- C. It takes 2 to 4 weeks for the drug to reach its full effect.
- D. Perhaps we need to change his medication.
Correct Answer: C
Rationale: Imipramine, a tricyclic antidepressant, typically requires 2 to 4 weeks to achieve therapeutic effects as it needs time to alter neurotransmitter levels. This response educates the sister accurately about the medication's timeline.
A client with a history of epilepsy is prescribed phenobarbital. The nurse should monitor the client for which of the following side effects?
- A. Drowsiness.
- B. Hypertension.
- C. Weight gain.
- D. Hyperglycemia.
Correct Answer: A
Rationale: Phenobarbital commonly causes drowsiness, which the nurse should monitor in clients with epilepsy.