Nokea
The nurse is performing a post-op assessment of an elderly client with a total hip repair. Although he has not requested medication for pain, the nurse suspects that the client's discomfort is severe and prepares to administer pain medication. Which of the following signs would not support the nurse's assessment of acute post-op pain?
- A. Increased blood pressure
- B. Inability to concentrate
- C. Dilated pupils
- D. Decreased heart rate
Correct Answer: D
Rationale: Acute pain typically increases heart rate, blood pressure, and pupil dilation. Decreased heart rate is not consistent with acute pain.
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A 15-month-old child has just been diagnosed with sickle cell anemia. The mother is pregnant and asks if the child she is carrying will also have sickle cell anemia. She says that neither she nor her husband has sickle cell anemia. The nurse's reply should be based on which understanding?
- A. There is a 50% chance that each child they have will have sickle cell anemia.
- B. The chance of having another child with sickle cell anemia is 1 in 4.
- C. Parents do not usually have two children in a row with sickle cell anemia.
- D. If the child is a boy, there is a 50% chance that he will have sickle cell anemia.
Correct Answer: B
Rationale: Sickle cell anemia is autosomal recessive; if both parents are carriers (trait), there's a 25% (1 in 4) chance per child of inheriting the disease, independent of gender or prior children.
A newborn weighed 7 pounds 2 ounces at birth. The nurse assesses the newborn at home 2 days later and finds the weight to be 6 pounds 7 ounces. What should the nurse tell the parents about this weight loss?
- A. The newborn needs additional assessments
- B. The mother should breast feed more often
- C. A change to formula is indicated
- D. The loss is within normal limits
Correct Answer: D
Rationale: The loss is within normal limits. A newborn is expected to lose 5-10% of the birth weight in the first few days post-partum because of changes in elimination and feeding.
The nurse is preparing to administer an injection of haloperidol decanoate (Haldol D).
- A. What is the most appropriate action for the nurse when administering haloperidol decanoate IM?
- B. Massage the injection site.
- C. Give deep IM in a large muscle mass.
- D. Use a 2 inch 25 gauge needle.
- E. Administer the medication in divided doses.
Correct Answer: B
Rationale: Haloperidol decanoate is highly irritating to subcutaneous tissue, requiring deep IM injection into a large muscle mass to ensure proper absorption and minimize irritation. Massaging the site, using a small-gauge needle, or dividing doses is inappropriate.
The nurse is caring for a client with a history of seizures.
- A. What is the priority action for the nurse during a client’s tonic-clonic seizure?
- B. Restrain the client’s limbs to prevent injury.
- C. Place a padded tongue blade in the client’s mouth.
- D. Turn the client to the side to maintain airway.
- E. Administer lorazepam (Ativan) immediately.
Correct Answer: C
Rationale: Turning the client to the side during a seizure maintains an open airway, preventing aspiration and ensuring oxygenation, which is the priority. Restraining limbs risks injury, tongue blades are contraindicated, and medication administration follows airway management.
The nurse is caring for a client with Ménière's disease. The nurse stands directly in front of the client when speaking. Which of the following BEST describes the rationale for the nurse's position?
- A. This enables the client to read the nurse's lips.
- B. The client does not have to turn her head to see the nurse.
- C. The nurse will have the client's undivided attention.
- D. There is a decrease in client's peripheral visual field.
Correct Answer: B
Rationale: by decreasing movement of client's head, vertigo attacks may be decreased