Nokea
The nurse transfers a client who received fentanyl 50 mcg IV push 10 minutes ago from the bed to a chair when the client becomes dizzy and falls into the chair. Which of the following actions would be appropriate for the nurse to take?
- A. Administer prescribed naloxone
- B. Assist the client back to bed
- C. Call a code blue
- D. Assess the client's vital signs
Correct Answer: B
Rationale: Dizziness after fentanyl administration suggests orthostatic hypotension; assisting the client back to bed ensures safety.
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What is a priority nursing assessment in the first 24 hours after admission of the client with a thrombotic stroke?
- A. Cholesterol level.
- B. Pupil size and pupillary response.
- C. Bowel sounds.
- D. Echocardiogram. SUPPRESSED
Correct Answer: B
Rationale: Pupil size and pupillary response are priority assessments to detect neurological deterioration, such as increased ICP or stroke extension. Cholesterol, bowel sounds, and echocardiograms are not immediate priorities.
A nurse is developing a care plan for a client with hepatic encephalopathy. Which of the following are goals for the care for this client? Select all that apply.
- A. Preventing constipation.
- B. Administering lactulose (Cephulac).
- C. Monitoring coordination while walking.
- D. Checking the pupil reaction.
- E. Increasing food and fluids high in carbohydrate.
- F. Encouraging physical activity.
Correct Answer: A,B
Rationale: Preventing constipation (A) and administering lactulose (B) reduce ammonia levels, key in managing hepatic encephalopathy. Coordination (C) and pupil reaction (D) are unrelated. High carbohydrates (E) and physical activity (F) are not primary goals.
The nurse is observing a client who is recovering from back strain lift a box as shown below. What should the nurse do?
- A. Praise the client for using correct body mechanics.
- B. Suggest to the client that she put both knees on the floor before attempting to lift the box.
- C. Advise the client to bend from the waist rather than stretching her back in this position.
- D. Inform the client that she should keep her back straight by squatting with both knees parallel.
Correct Answer: A
Rationale: The client is using correct body mechanics for lifting because she is keeping her back as straight as possible and is holding the box close to her body. She is using her large leg muscles to lift the box. She is using a broad base of support by placing her feet as wide apart as possible. The other suggestions would cause the client to put a strain on her back.
The rate at which I.V. fluids are infused is based on the burn client's:
- A. I.V. and body surface area (BSA) burned.
- B. Total body weight and BSA burned.
- C. Total BSA and BSA burned.
- D. Height and weight and BSA burned.
Correct Answer: B
Rationale: The Parkland Formula uses total body weight and percentage of BSA burned to calculate fluid requirements, ensuring adequate resuscitation based on burn severity.
A client post-inguinal herniorrhaphy reports scrotal swelling 24 hours after surgery. Which action should the nurse take first?
- A. Apply a warm compress to the scrotum.
- B. Notify the surgeon.
- C. Elevate the scrotum and apply ice.
- D. Administer a diuretic as ordered.
Correct Answer: C
Rationale: Elevating the scrotum and applying ice is the first action to reduce scrotal swelling post-inguinal herniorrhaphy, a common postoperative finding. Warm compresses may worsen swelling, notification is needed if swelling persists, and diuretics are not indicated. CN: Physiological adaptation; CL: Synthesize