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The nurse wishes to assess the quality of a patient’s pain. Which questions is appropriate to obtain this assessment if the patient is able to give a verbal response?
- A. “Is the pain constant or intermittent?”
- B. “Is the pain sharp, dull, or crushing?”
- C. “What makes the pain better? Worse?”
- D. “When did the pain start?”
Correct Answer: B
Rationale: The correct answer is B because asking if the pain is sharp, dull, or crushing helps assess the quality of pain, providing specific information on the type of sensation felt. This is crucial for understanding the underlying cause and guiding appropriate treatment.
A: Asking about pain being constant or intermittent addresses duration, not quality.
C: Inquiring about what makes pain better or worse focuses on triggers, not quality.
D: Asking when the pain started addresses onset time, not quality.
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An 80-year-old client is given morphine sulphate for postoperative pain. Which concomitant medication should the nurse question that poses a potential development of urinary retention in this geriatric client?
- A. Antacids.
- B. Tricyclic antidepressants.
- C. Nonsteroidal anti-inflammatory agents.
- D. Insulin.
Correct Answer: B
Rationale: The correct answer is B: Tricyclic antidepressants. Tricyclic antidepressants can cause anticholinergic effects, including urinary retention, especially in the elderly. Morphine sulfate can also contribute to urinary retention. Antacids (A) and nonsteroidal anti-inflammatory agents (C) are not known to cause urinary retention. Insulin (D) does not pose a risk for urinary retention in this scenario.
What should a designated healthcare surrogate base healthcare decisions on?
- A. Personal beliefs and values
- B. Recommendations of family members and friends
- C. Recommendations of the physician and healthcare team
- D. Wishes previously expressed by the patient
Correct Answer: C
Rationale: The correct answer is C because the healthcare surrogate should base decisions on recommendations of the physician and healthcare team who have the expertise to provide medical advice. They are best positioned to understand the patient's condition and treatment options. Personal beliefs (A) may not align with medical best practices. Family and friends' recommendations (B) may not be informed by medical knowledge. Wishes previously expressed by the patient (D) are important but may need to be interpreted in the context of the current medical situation, which healthcare professionals can provide.
The patient’s potassium level is 7.0 mEq/L. Besides dialysis, which of the following actually reduces plasma potassium levels and total body potassium content safely in a patient with renal dysfunction?
- A. Sodium polystyrene sulfonate
- B. Sodium polystyrene sulfonate with sorbitol
- C. Regular insulin
- D. Calcium gluconate
Correct Answer: C
Rationale: Correct Answer: C - Regular insulin
Rationale:
1. Insulin promotes cellular uptake of potassium.
2. When insulin is administered, it moves potassium from extracellular to intracellular space.
3. This decreases plasma potassium levels safely.
4. Other options do not directly lower potassium levels in the same manner.
Summary of Other Choices:
A: Sodium polystyrene sulfonate - exchanges sodium for potassium in the intestines, not reducing total body potassium.
B: Sodium polystyrene sulfonate with sorbitol - similar to A, does not reduce total body potassium.
D: Calcium gluconate - does not directly lower potassium levels, used for treating hyperkalemia-induced cardiac toxicity.
A patient receiving palliative care for advanced cancer reports fatigue and loss of appetite. Which intervention should the nurse prioritize?
- A. Encourage the patient to eat small, frequent meals.
- B. Administer prescribed appetite stimulants.
- C. Provide rest periods to reduce fatigue.
- D. Discuss the benefits of parenteral nutrition.
Correct Answer: C
Rationale: The correct answer is C: Provide rest periods to reduce fatigue. Prioritizing rest periods can help alleviate fatigue, a common symptom in patients with advanced cancer. Encouraging small, frequent meals (choice A) may not be effective if the patient has no appetite. Administering appetite stimulants (choice B) may not address the root cause of fatigue. Discussing parenteral nutrition (choice D) is not the priority as it does not directly address the fatigue and loss of appetite reported by the patient. Rest is essential for symptom management and overall well-being in palliative care.
The critical care nurse knows that in critically ill patients, renal dysfunction
- A. is a very rare problem.
- B. affects nearly two thirds of patients.
- C. has a low mortality rate once renal replacement therapy has been initiated.
- D. has little effect on morbidity, mortality, or quality of life.
Correct Answer: B
Rationale: The correct answer is B. Renal dysfunction is common in critically ill patients due to various factors like sepsis, hypotension, and nephrotoxic medications. This affects nearly two thirds of patients, making it a significant issue in critical care. Choices A, C, and D are incorrect. A is wrong because renal dysfunction is not rare in critically ill patients. C is incorrect as renal replacement therapy does not guarantee low mortality rates. D is inaccurate as renal dysfunction can have a significant impact on morbidity, mortality, and quality of life in critically ill patients.