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The nurse is caring for a postoperative client who underwent abdominal surgery and is receiving patient-controlled analgesia (PCA) with morphine for pain management. The nurse notes that the client is sedated but still complaining of severe pain. What is the most appropriate action for the nurse to take?
- A. Increase the PCA dosage
- B. Administer a non-opioid analgesic
- C. Discontinue PCA and Administer Intramuscular (IM) Morphine
- D. Notify the healthcare provider
Correct Answer: D
Rationale: Notifying the provider (D) is appropriate when the client is sedated yet in severe pain, indicating potential PCA inadequacy or complications requiring reassessment.
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A nurse is caring for a 57 year old client and is teaching them about screening for colorectal cancer. Which of the following information should the nurse include?
- A. It is recommended that colon cancer screening with a colonoscopy should begin at age 45.
- B. It is recommended that colon cancer screening with a colonoscopy should begin at age 70.
- C. It is recommended that colon cancer screening with a colonoscopy should begin at age 40.
- D. It is recommended that colon cancer screening with a colonoscopy should begin at age 65.
Correct Answer: A
Rationale: Current guidelines recommend colonoscopy screening for colorectal cancer starting at age 45 (A) for average-risk individuals.
The nurse is teaching a client about newly prescribed metoclopramide for nausea and vomiting. Which adverse reaction requires immediate follow-up?
- A. Dystonia
- B. Fever
- C. Drowsiness
- D. Diarrhea
Correct Answer: A
Rationale: Dystonia, an extrapyramidal symptom, is a serious adverse effect of metoclopramide requiring immediate follow-up due to its impact on movement. Fever, drowsiness, and diarrhea are less urgent side effects.
Which of the following clients does the nurse suspect would benefit most from placement of a nasogastric tube?
- A. A 9-year-old client with a femur fracture.
- B. An 82-year-old client with congestive heart failure.
- C. A 65-year-old client on dialysis.
- D. A 52-year-old client with leukemia who is receiving chemotherapy.
Correct Answer: D
Rationale: A client receiving chemotherapy (D) may experience severe nausea and vomiting, necessitating an NG tube for decompression or feeding. The other conditions are less likely to require NG tube placement.
The nurse is caring for a client with appendicitis. Which of the following statements are correct regarding this condition? Select all that apply.
- A. McBurney's point tenderness is a sign of appendicitis
- B. Appendicitis is more common among males
- C. A low carbohydrate diet is a risk factor for appendicitis
- D. Diagnosis of appendicitis is confirmed by endoscopic retrograde cholangiopancreatography
- E. The client may have an elevated white blood cell count (WBC)
Correct Answer: A,E
Rationale: McBurney's point tenderness (A) and elevated WBC (E) are hallmark signs of appendicitis. It is not more common in males (B), low-carb diets (C) are not a risk factor, and ERCP (D) is not used for diagnosis.
The nurse is teaching a client about the newly prescribed medication, esomeprazole. Which statements, if made by the client, would require further teaching? Select all that apply.
- A. I should take this medication with meals.
- B. Long term use of this medication may increase my risk for osteoporosis.
- C. The medication will coat my ulcer so I can eat without pain.
- D. I will need frequent laboratory tests while taking this medication.
- E. I may need to take magnesium supplements while on this medication.
Correct Answer: A,C,D
Rationale: Esomeprazole should be taken before meals, not with them; it reduces acid but does not coat ulcers; and routine lab tests are not typically required. Osteoporosis risk and magnesium supplementation are valid concerns.