Nokea
The nurse is reviewing new medication prescriptions for assigned clients. The nurse should clarify the prescription for?
- A. PO oxycodone for a client who had a total hip replacement 1 day ago, has a history of buspirone use, and is reporting pain rated as 6 on a scale of 0-10
- B. PO tramadol for a client who had a laparoscopic cholecystectomy 1 day ago, has a history of nicotine use, and is reporting pain rated as 5 on a scale of 0-10
- C. transdermal fentanyl for a client who had an above-the-knee amputation 2 days ago, has a history of cocaine use, and is reporting pain rated as 8 on a scale of 0-10
- D. transdermal lidocaine 5% for a client who has chronic postherpetic neuralgia, has a history of alcohol use, and is reporting pain rated as 7 on a scale of 0-10
Correct Answer: C
Rationale: Transdermal fentanyl is typically reserved for chronic pain, not acute postoperative pain, and requires clarification.
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An adult who recently had an amputation has an above-the-knee prosthesis. Which nursing action will do the most to help the client adjust to the prosthesis?
- A. Adjust the prosthesis for the client.
- B. Offer the client a cane or a walker for ease of movement.
- C. Place an 'at risk for fall' sign on the client's door.
- D. Allow the client to manage his own care.
Correct Answer: D
Rationale: Allowing self-management fosters independence and confidence with the prosthesis, promoting adjustment.
The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.
The nurse is to observe the client for shock. The client's admitting vital signs are blood pressure (BP)=116/70, pulse=86, and respirations=24. Which finding, if observed, would be most suggestive of shock?
- A. BP=140/60
- B. Pulse=100
- C. BP=114/68
- D. Pulse=60
Correct Answer: B
Rationale: Increased pulse (tachycardia) is a hallmark of shock, compensating for reduced volume. Stable or slightly varied BP and low pulse are less indicative.
Which of the following symptoms is associated with exacerbation of multiple sclerosis?
- A. Anorexia
- B. Seizures
- C. Diplopia
- D. Insomnia
Correct Answer: C
Rationale: Diplopia (double vision) is a common symptom during multiple sclerosis exacerbations, resulting from demyelination affecting the optic nerves or brainstem.
A client with methicillin-resistant Staphylococcus aureus (MRSA) bacteremia has been receiving IV vancomycin for the last 3 days. Which blood test trend is most important for the nurse to review when preparing to administer this medication?
- A. Blood cultures
- B. Creatinine levels
- C. Magnesium levels
- D. White blood cell (WBC) count
Correct Answer: B
Rationale: Vancomycin can cause nephrotoxicity, so monitoring creatinine levels is critical to assess kidney function.