Nokea
The nurse is caring for a client who is receiving prescribed fentanyl. Which of the following findings would indicate the client is having a side effect? Select all that apply.
- A. Nausea and vomiting
- B. Constipation
- C. Pruritus
- D. Urinary retention
- E. Nystagmus
Correct Answer: A,B,C,D
Rationale: Fentanyl, an opioid, commonly causes nausea, constipation, pruritus, and urinary retention. Nystagmus is not a typical side effect.
You may also like to solve these questions
Which of the following medications would be appropriate for the treatment of an allergic reaction to a blood transfusion? Select all that apply.
- A. Epinephrine
- B. Acetaminophen
- C. Diphenhydramine
- D. Hydrocortisone
- E. Pantoprazole
Correct Answer: A,C,D
Rationale: Epinephrine treats severe allergic reactions (anaphylaxis), diphenhydramine manages mild to moderate allergic symptoms, and hydrocortisone reduces inflammation in allergic reactions. Acetaminophen is for fever or pain, and pantoprazole is for gastric issues, not allergic reactions.
The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply.
- A. I will need to dispose of my old clothing when I return home.
- B. I should always cover my mouth and nose when sneezing.
- C. I'll be important that I isolate myself from family when possible.
- D. I should use paper tissues to cough in and dispose of them promptly.
- E. I can use regular plates and utensils whenever I eat.
Correct Answer: B,D,E
Rationale: Covering the mouth when sneezing (B), using tissues for coughing and disposing of them (D), and using regular utensils (E) prevent tuberculosis spread. Disposing of clothing is unnecessary. Isolation is only needed until the client is non-infectious (after 2–3 weeks of treatment).
The client with an intestinal obstruction continues to have acute pain even though the nasoenteric tube is patent and draining. Which action by the nurse would be most appropriate?
- A. Reassure the client that the nasoenteric tube is functioning.
- B. Assess the client for a rigid abdomen.
- C. Administer an opioid as ordered.
- D. Reposition the client on the left side.
Correct Answer: B
Rationale: Persistent acute pain despite a patent nasoenteric tube suggests a complication like peritonitis, indicated by a rigid abdomen, which requires immediate assessment. Reassurance, opioids, or repositioning may delay addressing a serious issue. CN: Physiological adaptation; CL: Synthesize
A client has been diagnosed with adenocarcinoma of the stomach and is scheduled to undergo a subtotal gastrectomy (Billroth II procedure). During preoperative teaching, the nurse is reinforcing information about the surgical procedure. Which of the following explanations is most accurate?
- A. The procedure will result in enlargement of the pyloric sphincter.
- B. The procedure will result in anastomosis of the gastric stump to the jejunum.
- C. The procedure will result in removal of the duodenum.
- D. The procedure will result in repositioning of the vagus nerve.
Correct Answer: B
Rationale: The Billroth II procedure involves anastomosis of the gastric stump to the jejunum, bypassing the duodenum. The other options are incorrect descriptions of the procedure.
Regular oral hygiene is essential for the client who has had a stroke. Which of the following nursing measures is not appropriate when providing oral hygiene?
- A. Placing the client on the back with a small pillow under the head.
- B. Keeping portable suctioning equipment at the bedside.
- C. Opening the client's mouth with a padded tongue blade.
- D. Cleaning the client's mouth and teeth with a toothbrush.
Correct Answer: A
Rationale: Placing the client on their back increases the risk of aspiration, especially in stroke patients with impaired swallowing. Suction equipment, padded tongue blades, and toothbrushing are appropriate for safe oral hygiene.