Nokea
The nurse is caring for all of the following clients. Who is probably at greatest risk for skin breakdown and will need special nursing care measures?
- A. A 75-year-old who is admitted with a broken hip
- B. An 80-year-old who is admitted with angina
- C. An 85-year-old who is admitted for diagnostic tests
- D. A 78-year-old who is admitted with asthma
Correct Answer: A
Rationale: A broken hip limits mobility, increasing pressure ulcer risk due to prolonged immobility, requiring special skin care measures.
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A client is given morphine 6 mg IV push for postoperative pain.
- A. What is the most appropriate nursing action for a client with pulse 68, respirations 8, BP 100/68, and sleeping quietly after receiving morphine 6 mg IV?
- B. Allow the client to sleep undisturbed.
- C. Administer oxygen via facemask or nasal prongs.
- D. Administer naloxone (Narcan).
- E. Place epinephrine 1:1,000 at the bedside.
Correct Answer: C
Rationale: A respiratory rate of 8 indicates respiratory depression, a serious side effect of morphine. Administering naloxone (Narcan) is the most appropriate action to reverse this effect. Allowing the client to sleep risks further respiratory compromise, oxygen may be used after naloxone, and epinephrine is not indicated.
A client with schizophrenia is receiving haloperidol (Haldol) 5 mg T.I.D. The client's family is alarmed and calls the clinic when 'his eyes rolled upward.' The nurse recognizes this as what type of side effect?
- A. Oculogyric crisis
- B. Tardive dyskinesia
- C. Nystagmus
- D. Dysphagia
Correct Answer: A
Rationale: Oculogyric crisis. This refers to involuntary muscle spasm of the eye, a known side effect of haloperidol.
Which individual is at greatest risk for developing hypertension?
- A. 45 year-old African American attorney
- B. 60 year-old Asian American shop owner
- C. 40 year-old Caucasian nurse
- D. 55 year-old Hispanic teacher
Correct Answer: A
Rationale: 45 year-old African American attorney. The incidence of hypertension is greater among African Americans than other groups in the US. The incidence among the Hispanic population is rising.
The nurse is caring for a post-operative client who develops a wound evisceration. The first nursing intervention should be
- A. medicate the client for pain
- B. call the provider
- C. cover the wound with sterile saline dressing
- D. place the bed in a flat position
Correct Answer: C
Rationale: When evisceration occurs, the wound should first be quickly covered by sterile dressings soaked in sterile saline. This prevents tissue damage until a repair can be effected.
The nurse is caring for a client admitted to the hospital with right lower lobe (RLL) pneumonia. On assessment, the nurse notes crackles over the RLL. The client has significant pleuritic pain and is unable to take in a deep breath in order to cough effectively. Which nursing diagnosis would be most appropriate for this client based on this assessment data?
- A. Impaired gas exchange related to acute infection and sputum production
- B. Ineffective airway clearance related to sputum production and ineffective cough
- C. Ineffective breathing pattern related to acute infection
- D. Anxiety related to hospitalization and role conflict
Correct Answer: B
Rationale: Ineffective airway clearance is defined as the inability to cough effectively, directly supported by the assessment data of crackles and ineffective cough.