Nokea
The nurse is caring for a client who is receiving the prescribed hydromorphone. Which of the following side effects should the nurse look for in the client? Select all that apply.
- A. Urinary incontinence
- B. Pupil dilation
- C. Diarrhea
- D. Altered level of consciousness (LOC)
- E. Constipation
Correct Answer: D,E
Rationale: Hydromorphone, an opioid, can cause altered level of consciousness and constipation. Urinary incontinence, pupil dilation, and diarrhea are not typical side effects.
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The nurse is teaching a client who is scheduled for a transfusion of one unit of packed red blood cells (PRBCs). Which of the following information should the nurse include?
- A. A baseline weight will be taken before the start of the transfusion.
- B. I will be with you during the transfusion's first fifteen minutes.
- C. You will need to provide a urine sample at the end of the transfusion.
- D. Please complete the required surgical consent before the transfusion.
Correct Answer: B
Rationale: The nurse must stay with the client during the first 15 minutes of a PRBC transfusion to monitor for acute reactions, which are most likely to occur early. Baseline weight is relevant for fluid overload risk, not routine. Urine samples are not standard, and surgical consent is not required for transfusions.
A client in the PACU after spinal anesthesia reports a severe headache when sitting up. The nurse suspects:
- A. Dehydration.
- B. Post-dural puncture headache.
- C. Hypertension.
- D. Migraine exacerbation.
Correct Answer: B
Rationale: A severe headache worsened by sitting up after spinal anesthesia is characteristic of a post-dural puncture headache due to cerebrospinal fluid leakage. This requires prompt management, such as hydration or an epidural blood patch.
An older, sedentary adult may not respond to emotional or physical stress as well as a younger individual because of:
- A. Left ventricular atrophy.
- B. Irregular heartbeats.
- C. Peripheral vascular occlusion.
- D. Pacemaker placement.
Correct Answer: A
Rationale: Aging leads to left ventricular atrophy, reducing cardiac reserve and impairing the heart's ability to respond to stress, unlike irregular heartbeats or pacemakers.
Which dietary restriction is critical in acute renal failure?
- A. Low sodium.
- B. High protein.
- C. Low carbohydrate.
- D. High potassium.
Correct Answer: A
Rationale: Low sodium prevents fluid retention and hypertension in acute renal failure.
A priority goal for the hospitalized client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy would be to:
- A. Decrease secretions.
- B. Instruct the client in caring for the tracheostomy.
- C. Relieve anxiety related to the tracheostomy.
- D. Maintain a patent airway.
Correct Answer: D
Rationale: Maintaining a patent airway is the priority goal post-laryngectomy with a new tracheostomy to ensure adequate oxygenation and prevent respiratory distress.