Nokea
The nurse received a male client from the postanesthesia care unit. Which assessment data would warrant immediate intervention?
- A. The client's vital signs are T 97°F, P 108, R 24, and BP 80/40.
- B. The client is sleepy but opens the eyes to his name.
- C. The client is complaining of pain at a '5' on a 1-to-10 pain scale.
- D. The client has 20 mL of urine in the urinary drainage bag.
Correct Answer: A
Rationale: Tachycardia, tachypnea, and hypotension (80/40) suggest hypovolemic shock, requiring immediate intervention. Sleepiness, moderate pain, and low urine output are less urgent.
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Which problem should the nurse identify as priority for client who is one (1) day postoperative?
- A. Potential for hemorrhaging.
- B. Potential for injury.
- C. Potential for fluid volume excess.
- D. Potential for infection.
Correct Answer: A
Rationale: Hemorrhaging is a life-threatening risk in the first 24–48 hours post-surgery, the priority. Injury, fluid excess, and infection are secondary.
The three (3)-day postoperative client is complaining of unrelieved pain at the incision site one (1) hour after the administration of narcotic pain medication. Which action should the nurse implement first?
- A. Check the MAR for another medication to administer.
- B. Teach the client to use guided imagery to relieve the pain.
- C. Assess the client for complications.
- D. Elevate the head of the client's bed.
Correct Answer: C
Rationale: Unrelieved pain post-narcotic may indicate complications (e.g., infection, hematoma), requiring assessment first. Additional medication, imagery, or HOB elevation follow.
The nurse clears the PCA pump and discovers the client has used only a small amount of medication during the shift. Which intervention should the nurse implement?
- A. Determine why the client is not using the PCA pump.
- B. Document the amount and take no action.
- C. Chart the client is not having pain.
- D. Contact the HCP and request oral medication.
Correct Answer: A
Rationale: Determining why the client underuses the PCA (e.g., misunderstanding, side effects) ensures effective pain management. Documentation alone, assuming no pain, or changing medication is premature.
The nurse is administering an opioid narcotic to the client. Which interventions should the nurse implement for client safety? Select all that apply.
- A. Compare the hospital number on the MAR to the client's bracelet.
- B. Have a witness verify the wasted portion of the narcotic.
- C. Assess the client's vital signs prior to administration.
- D. Determine if the client has any allergies to medications.
- E. Clarify all pain medication orders with the health-care provider.
Correct Answer: A,B,C,D
Rationale: Verifying ID, witnessing waste, checking vital signs, and confirming allergies ensure opioid safety. Clarifying all orders is unnecessary unless unclear.
Which situation is an example of the nurse fulfilling the role of client advocate?
- A. The nurse brings the client pain medication when it is due.
- B. The nurse collaborates with other disciplines during the care conference.
- C. The nurse contacts the health-care provider when pain relief is not obtained.
- D. The nurse teaches the client to ask for medication before the pain gets to a '5.'
Correct Answer: C
Rationale: Contacting the HCP for inadequate pain relief advocates for the client’s comfort. Bringing medication, collaborating, and teaching are supportive but less advocacy-focused.