Nokea
The nurse is caring for assigned clients. The nurse should first assess the client who had a
- A. cholecystectomy 4 hours ago and is reporting drowsiness and nausea
- B. laminectomy 8 hours ago and is reporting pain as 5 on a scale of 0-10
- C. myomectomy 12 hours ago and has a small amount of sanguineous drainage on the surgical dressing
- D. transurethral resection of the prostate 16 hours ago and has pink-tinged urine in the urinary drainage bag
Correct Answer: A
Rationale: Drowsiness and nausea 4 hours post-cholecystectomy (A) may indicate complications like bleeding or anesthesia effects, requiring priority assessment. Pain (B), minor drainage (C), and pink urine (D) are less urgent.
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The nurse is preparing to irrigate the wound of a 7-year-old client who sustained a laceration while on a playground. Which of the following actions should the nurse take? Select all that apply.
- A. Administer a prescribed analgesic 30 minutes before irrigating the wound
- B. Cleanse the wound from the most contaminated to the least contaminated area
- C. Obtain a 10-mL syringe and a 27-gauge needle
- D. Review the client's vaccination record
- E. Use continuous pressure to flush the wound and repeat until the drainage is clear
Correct Answer: A,D,E
Rationale: Analgesics (A), checking vaccinations (D) for tetanus risk, and continuous flushing (E) are appropriate. Cleaning from contaminated to clean (B) is incorrect, and a 27-gauge needle (C) is too small for irrigation.
Discharge medications
Albuterol: 2 puffs every 4-6 hours as needed
Prednisone: 40 mg PO daily
Naproxen: 220 mg PO twice daily
Tiotropium: 1 capsule inhaled daily
A client with a history of degenerative arthritis is being discharged home following exacerbation of chronic obstructive pulmonary disease. After reviewing the discharge medications, the nurse should reinforce which of the following topics with the client? Select all that apply.
- A. Dryness of the mouth and throat may occur
- B. Ringing in the ears is an expected, transient side effect
- C. The albuterol canister should not be shaken before use
- D. The health care provider should be notified if stools are black and tarry
- E. Tiotropium capsules should not be swallowed
Correct Answer: A,D,E
Rationale: Dry mouth (A) is a side effect of COPD medications, black stools (D) may indicate GI bleeding, and tiotropium capsules are inhaled, not swallowed (E). Ringing in ears (B) is not expected, and albuterol should be shaken (C).
The nurse is caring for a client with bulimia nervosa. It would be a priority for the nurse to
- A. place limits on the time allowed for client meals
- B. check on the client at irregular intervals during the overnight hours
- C. monitor the client for 1 to 2 hours after each meal
- D. discuss complications associated with bulimia nervosa with the client
Correct Answer: C
Rationale: Monitoring for 1-2 hours after meals (C) prevents purging, a priority in bulimia management. Time limits (A) may increase anxiety, overnight checks (B) are less relevant, and discussing complications (D) is educational but not immediate.
An RN who usually works in a spinal rehabilitation unit is floated to the emergency department. Which of these clients should the charge nurse assign to this RN?
- A. A middle-aged client who says 'I took too many diet pills' and 'my heart feels like it is racing out of my chest.'
- B. A young adult who says 'I hear songs from heaven. I need money for beer. I quit drinking 2 days ago for my family. Why are my arms and legs jerking?'
- C. An adolescent who was recently diagnosed with leukemia and started chemotherapy with an initial assessment finding of pinpoint pupils and a relaxed respiratory rate of 10
- D. An elderly client who reports having taken a 'large crack hit' 10 minutes prior to walking into the emergency room
Correct Answer: C
Rationale: Nurses who are floated to other units should be assigned to a client who has minimal anticipated immediate complications of their problem. The client in option C exhibits opioid toxicity with the pinpoint pupils and has the least risk of complications occurring in the near future.
The nurse is preparing to give an adult a subcutaneous injection of heparin. What should the nurse check prior to giving the medication?
- A. International normalized ratio (INR)
- B. Bleeding time
- C. Prothrombin time
- D. Partial thromboplastin time
Correct Answer: D
Rationale: Partial thromboplastin time (PTT) monitors heparin's anticoagulant effect, ensuring safe administration by assessing bleeding risk.