Nokea
The nurse should monitor the surgical client closely for which clinical manifestation with the administration of naloxone (Narcan)?
- A. Dizziness.
- B. Biliary colic.
- C. Bleeding.
- D. Urine retention.
Correct Answer: A
Rationale: Naloxone can cause dizziness due to rapid reversal of opioid effects, leading to autonomic changes. This is a common side effect to monitor in surgical clients.
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A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3ˆ’, 36 mEq/L. The nurse should assess the client for?
- A. Cyanosis.
- B. Flushed skin.
- C. Irritability.
- D. Anxiety.
Correct Answer: C
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2) with adequate oxygenation (PaO2 80). Irritability is a symptom of CO2 retention. Cyanosis requires lower PaO2. Flushed skin and anxiety are less specific.
After teaching the client with a femoral fracture about the purpose of treatment with skeletal traction, which of the following, if stated by the client, would indicate the need for additional teaching?
- A. To align injured bones.
- B. To provide long-term pull.
- C. To apply 25 lb of traction.
- D. To pull weight with a boot.
Correct Answer: C
Rationale: The amount of traction (e.g., 25 lb) is specific to the injury and not a general purpose, indicating a misunderstanding.
The nurse is teaching a client post-appendectomy about activity restrictions. Which instruction is most appropriate?
- A. Avoid lifting more than 10 pounds for 4–6 weeks.
- B. Resume full activity within 1 week.
- C. Avoid walking for at least 2 weeks.
- D. Perform sit-ups to strengthen abdominal muscles.
Correct Answer: A
Rationale: Avoiding lifting more than 10 pounds for 4–6 weeks prevents strain on the surgical site post-appendectomy. Resuming full activity too soon, avoiding walking, or doing sit-ups could impair healing. CN: Physiological adaptation; CL: Synthesize
A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?
- A. Use your nasal decongestant spray regularly to help clear your nasal passages.
- B. Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.
- C. It is important to increase your activity. A daily brisk walk will help promote drainage.
- D. Keep a diary of when your symptoms occur. This is a very small amount of the drug. You identify what precipitates your attacks.
Correct Answer: D
Rationale: Keeping a symptom diary helps identify triggers for allergic rhinitis, enabling avoidance or management strategies. Overuse of decongestant sprays can cause rebound congestion. Antibiotics are ineffective for allergic rhinitis, which is not bacterial. Increased activity like walking does not directly alleviate allergic rhinitis symptoms.
Which of the following variables is most important to assess when determining the impact of the cancer diagnosis and treatment modalities on a long-term survivor's quality of life?
- A. Occupation and employability.
- B. Functional status.
- C. Evidence of disease.
- D. Individual values and beliefs.
Correct Answer: B
Rationale: Functional status, including physical and emotional capabilities, is the most important variable affecting a long-term cancer survivor's quality of life, as it reflects their ability to engage in daily activities.