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.
You may also like to solve these questions
A 19-year-old woman has just started taking birth control pills. She calls the clinic nurse to say that her breasts are tender and she is nauseous. The nurse's response is based on which understanding?
- A. These are serious side effects.
- B. These effects usually decrease after three to six cycles.
- C. Taking the pill in the morning reduces its side effects.
- D. Taking the pills every other day reduces its side effects.
Correct Answer: B
Rationale: Breast tenderness and nausea are common initial side effects of oral contraceptives, typically resolving after a few cycles.
In providing care for a client with pain from a sickle cell crisis, which one of the following medication orders for pain control should be questioned by the nurse?
- A. Demerol
- B. Morphine
- C. Methadone
- D. Codeine
Correct Answer: A
Rationale: Demerol. Meperidine is not recommended in clients with sickle cell disease. Normeperidine, a metabolite of meperidine, is a central nervous system stimulant that produces anxiety, tremors, myoclonus, and generalized seizures when it accumulates with repetitive dosing. Clients with sickle cell disease are particularly at risk for normeperidine-induced seizures.
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.
The nurse is administering the loop diuretic furosemide (Lasix) to the client diagnosed with essential hypertension. Which assessment data would warrant the nurse to question administering the medication?
- A. The client's potassium level is 4.2 mEq/L.
- B. The client's urinary output is greater than the intake.
- C. The client has tented skin turgor and dry mucous membranes.
- D. The client has lost two (2) pounds in the last 24 hours.
Correct Answer: C
Rationale: Tented skin turgor and dry membranes indicate dehydration, a contraindication for Lasix, which could worsen fluid loss. Normal potassium, output, or weight loss are expected.
The health care provider orders an IV aminophylline infusion at 30 mg/hr. The pharmacy sends a 1,000 ml bag of D5W containing 500 mg of aminophylline. In order to administer 30 mg per hour, the RN will set the infusion rate at:
- A. 20 ml per hour
- B. 30 ml per hour
- C. 50 ml per hour
- D. 60 ml per hour
Correct Answer: D
Rationale: 60 ml per hour. Using the ratio method to calculate infusion rate: mg to be given (30) : ml to be infused (X) :: mg available (500) : ml of solution (1,000). Solve for X by cross-multiplying: 30 × 1,000 = 500 × X, 30,000 = 500X, X = 30,000 / 500, X = 60 ml per hour.