Nokea
The nurse is caring for an elderly client who is eight (8) hours postoperative hip replacement and is reporting incisional pain. Which intervention is priority for this client?
- A. Assist the client to sit in the bedside chair.
- B. Initiate pain medication at the lowest dose.
- C. Assess the client's pupil size and accommodation.
- D. Monitor the client's urinary output hourly.
Correct Answer: B
Rationale: Pain management is the priority post-op to promote recovery and comfort; lowest dose minimizes side effects in the elderly. Sitting, pupil assessment, or urine output are secondary.
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The client asks the clinic nurse if he should take 2,000 mg of vitamin C a day to prevent getting a cold. On which scientific rationale should the nurse base the response?
- A. Vitamin C in this dosage will help cure the common cold.
- B. This vitamin must be taken with echinacea to be effective.
- C. This dose of vitamin C is not high enough to help prevent colds.
- D. Megadoses of vitamin C may cause crystals to form in the urine.
Correct Answer: D
Rationale: Megadoses of vitamin C (>2,000 mg/day) can lead to oxalate crystal formation in urine, increasing kidney stone risk. Evidence for cold prevention is weak, and echinacea or higher doses are not supported.
The unlicensed assistive personnel (UAP) reported an intake of 1,000 mL and a urinary output of 1,500 mL for a client who received a thiazide diuretic this morning. Which nursing task could the nurse delegate to the nursing assistant?
- A. Instruct the UAP to restrict the client's fluid intake.
- B. Request the UAP to insert a Foley catheter with an urometer.
- C. Tell the UAP urinary outputs are no longer needed.
- D. Ask the UAP to document fluids on the bedside I & O record.
Correct Answer: D
Rationale: Documenting I&O is within UAP scope; fluid restriction, catheter insertion, or discontinuing monitoring require nursing judgment.
The employee health nurse is observing a student nurse administer a PPD tuberculin test to a new employee. Which behavior would warrant immediate intervention by the employee health nurse?
- A. The student nurse inserts the needle at a 45-degree angle.
- B. The student nurse cleanses the forearm with alcohol.
- C. The student nurse circles the injection site with ink.
- D. The student nurse instructs the employee to return in three (3) days.
Correct Answer: A
Rationale: PPD tests require a 10–15-degree angle for intradermal injection to form a wheal; 45 degrees is incorrect and warrants intervention. Other actions are standard.
For which client should the nurse question administering the muscarinic cholinergic agonist oxybutynin (Ditropan)?
- A. The client diagnosed with overactive bladder.
- B. The client diagnosed with type 2 diabetes.
- C. The client diagnosed with glaucoma.
- D. The client diagnosed with peripheral vascular disease.
Correct Answer: C
Rationale: Oxybutynin’s anticholinergic effects can increase intraocular pressure, contraindicating it in glaucoma. It’s appropriate for overactive bladder; diabetes or PVD are not contraindications.
A client in respiratory distress is admitted with arterial blood gas results of PH 7.30, PO2 58, PCO2 34, and HCO3 19. The nurse determines that the client is in
- A. metabolic acidosis
- B. metabolic alkalosis
- C. respiratory acidosis
- D. respiratory alkalosis
Correct Answer: A
Rationale: metabolic acidosis. These lab values indicate metabolic acidosis: the PH is low, PCO2 is normal, and bicarbonate level is low.