Nokea
The nurse is caring for a client who is postoperative day 3 following a bowel resection. The client reports sudden, severe abdominal pain and distention. Which of the following actions should the nurse take FIRST?
- A. Administer pain medication as ordered.
- B. Notify the physician.
- C. Assess the client’s vital signs and abdomen.
- D. Encourage the client to ambulate.
Correct Answer: B
Rationale: sudden, severe abdominal pain and distention may indicate a complication such as an anastomotic leak, requiring immediate physician notification
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A client with rheumatoid arthritis is beginning to develop flexion contractures of the knees. The nurse should tell the client to:
- A. Lie prone and let her feet hang over the mattress edge
- B. Lie supine, with her feet rotated inward
- C. Lie on her right side and point her toes downward
- D. Lie on her left side and allow her feet to remain in a neutral position
Correct Answer: A
Rationale: Lying prone with feet hanging over the mattress edge promotes knee extension, helping to prevent or reduce flexion contractures in rheumatoid arthritis.
A neurological consult has been ordered for a pediatric client with suspected absence seizures. The client with absence seizures can be expected to have:
- A. Short, abrupt muscle contractions
- B. Quick, severe bilateral jerking movements
- C. Abrupt loss of muscle tone
- D. Brief lapse in consciousness
Correct Answer: D
Rationale: Absence seizures cause brief lapses in consciousness, often appearing as staring spells, without motor symptoms.
A client has returned from surgery after removal of a tumor of the colon and creation of a temporary colostomy. She refuses to take a deep breath and cough then refuses to turn. Which of the following should the nurse assess first in trying to understand her lack of cooperation?
- A. Delirium status.
- B. Vital signs.
- C. Oxygen saturation.
- D. Level of pain.
Correct Answer: D
Rationale: Pain (D) is the most likely reason for refusing to cough or turn post-surgery, as these actions can exacerbate discomfort. Assessing pain first guides appropriate interventions. Delirium (A), vital signs (B), and oxygen saturation (C) are secondary.
A client has been receiving Rheumatrex (methotrexate) for severe rheumatoid arthritis. The nurse should tell the client to avoid taking:
- A. Aspirin
- B. Multivitamins
- C. Omega 3 fish oils
- D. Acetaminophen
Correct Answer: A
Rationale: Aspirin can increase methotrexate toxicity by reducing its renal excretion, leading to potentially severe side effects.
A client with obsessive compulsive personality disorder annoys his coworkers with his rigid-perfectionistic attitude and his preoccupation with trivial details. An important nursing intervention for this client would be:
- A. Helping the client develop a plan for changing his behavior
- B. Contracting with him for the time he spends on a task
- C. Avoiding a discussion of his annoying behavior because it will only make him worse
- D. Encouraging him to set a time schedule and deadlines for himself
Correct Answer: D
Rationale: Setting a time schedule helps the client manage perfectionistic tendencies by structuring tasks, reducing preoccupation with trivial details.