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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Ear drops have been ordered for a 10-month-old child. How should the nurse teach the mother to pull the baby's ear to straighten the ear canal?
- A. Down and back
- B. Down and forward
- C. Up and forward
- D. Up and back
Correct Answer: A
Rationale: In children under 3, pulling the ear down and back straightens the ear canal for proper ear drop administration.
An adult client is on call for the operating room. The preoperative medication order is for meperidine HCl (Demerol) 100 mg IM and atropine 0.4 mg IM. The operating room calls at 11:00 A.M. and requests that the client be medicated. The nurse notes that the client last received meperidine for pain at 10:00 A.M. What is the most appropriate action for the nurse to take?
- A. Give the preoperative medication as ordered
- B. Give half the dose of meperidine and all of the atropine
- C. Check with the anesthesiologist before administering the medication
- D. Withhold both the meperidine and the atropine
Correct Answer: C
Rationale: Recent meperidine administration increases the risk of respiratory depression. Consulting the anesthesiologist ensures safe dosing.
The nurse is assessing a client who is on long term glucocorticoid therapy. Which of the following findings would the nurse expect?
- A. Buffalo hump
- B. Increased muscle mass
- C. Peripheral edema
- D. Jaundice
Correct Answer: A
Rationale: Buffalo hump. With high doses of glucocorticoid, iatrogenic Cushing's syndrome develops. The exaggerated physiological action causes abnormal fat distribution which results in a moon-shaped face, an intrascapular pad on the neck (buffalo hump) and truncal obesity with slender limbs.
The client with epilepsy is prescribed carbamazepine (Tegretol), an anticonvulsant. Which discharge instruction should the nurse include in the teaching?
- A. Wear SPF 15 sunscreen when outside.
- B. Obtain regular serum drug levels.
- C. Be sure to floss teeth daily.
- D. Instruct the client to take tub baths only.
Correct Answer: B
Rationale: Carbamazepine requires serum level monitoring to ensure therapeutic range and avoid toxicity. Sunscreen, flossing, or baths are less relevant.
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.