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The nurse is planning care for a client who had surgery for abdominal aortic aneurysm repair 2 days ago. The pain medication and the use of relaxation and imagery techniques are not relieving the client's pain and the client refuses to get out of bed to ambulate as ordered. The nurse contacts the physician, explains the situation, and provides information about drug dose, frequency of administration, the client's vital signs, and the client's score on the pain scale. The physician tells the nurse that the current order for pain medication is sufficient and the client will be fine in a few days. The nurse should next:
- A. Explain to the physician that the current pain medication and other strategies are not helping the client and it is making it difficult for the client to ambulate as ordered
- B. Ask the hospitalist to write an order for a stronger pain medication
- C. Wait until the next shift and ask the nurse on that shift to contact the physician
- D. Report the incident to the team leader
Correct Answer: A
Rationale: The nurse should advocate for the client by reiterating to the physician that the current pain management is ineffective, preventing ambulation, which is critical for recovery post-AAA repair. This aligns with ethical and professional standards. Asking another provider, waiting, or reporting to the team leader delays care.
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A client who underwent a lobectomy and has a water-seal chest drainage system is breathing with a little more effort and at a faster rate than 1 hour ago. The client's pulse rate is also increased. The nurse should:
- A. Check the tubing to ensure that the client is not lying on it or kinking it.
- B. Increase the suction.
- C. Lower the drainage bottles 2 to 3 feet below the level of the client's chest.
- D. Ensure that the chest tube has two clamps on it to prevent air leaks.
Correct Answer: A
Rationale: Increased respiratory effort, rate, and pulse suggest a possible obstruction; checking for kinked or compressed tubing is the first step. Increasing suction, lowering bottles, or clamping tubes risks worsening the issue.
The nurse has asked the nursing assistant to ambulate a client with Parkinson's disease. The nurse observes the nursing assistant pulling on the client's arms to get the client to walk forward. The nurse should:
- A. Have the nursing assistant keep a steady pull on the client to promote forward ambulation.
- B. Explain how to overcome a freezing gait by telling the client to march in place.
- C. Assist the nursing assistant with getting the client back in bed.
- D. Give the client a muscle relaxant.
Correct Answer: B
Rationale: Teaching the client to march in place helps overcome freezing gait, a common Parkinson's symptom. Pulling on arms is unsafe, returning to bed is unnecessary, and muscle relaxants are inappropriate.
The wife of a terminally ill client asks the nurse, 'Why is my husband having frequent bowel movements if he is not eating?' Which of the following responses by the nurse informs the wife about the client's condition?
- A. I know he is having frequent loose stools and it is distressing for you, but that's just the way it is.
- B. I don't know when the bowels will shut down, but they will eventually.
- C. The pain medication will eventually help to slow the process of bowel function.
- D. The intestines still produce some waste products even when a person is not eating.
Correct Answer: D
Rationale: The intestines continue to produce waste from residual secretions and cellular turnover, even with minimal intake, explaining the frequent bowel movements.
Which of the following hospitalized clients is at risk to develop parotitis?
- A. A 50-year-old client with nausea and vomiting who is on nothing-by-mouth status.
- B. A 75-year-old client with diabetes who has ill-fitting dentures.
- C. An 80-year-old client who has poor oral hygiene and is dehydrated.
- D. A 65-year-old client with lung cancer who has a feeding tube in place.
Correct Answer: C
Rationale: Dehydration and poor oral hygiene in the 80-year-old client increase the risk of parotitis due to reduced saliva production and bacterial overgrowth.
The client with gastroesophageal reflux disease (GERD) complains of a chronic cough. The nurse understands that in a client with GERD this symptom is indicative of which of the following conditions?
- A. Development of laryngeal cancer.
- B. Irritation of the esophagus.
- C. Esophageal scar tissue formation.
- D. Aspiration of gastric contents.
Correct Answer: D
Rationale: A chronic cough in GERD is often due to aspiration of gastric contents into the respiratory tract, irritating the airways. The other options are less directly related to this symptom.