Nokea
The physician has ordered Stadol (butorphanol) for a post-operative client. The nurse knows that the medication is having its intended effect if the client:
- A. Is asleep 30 minutes after the injection
- B. Asks for extra servings on his meal tray
- C. Has an increased urinary output
- D. States that he is feeling less nauseated
Correct Answer: A
Rationale: Being asleep 30 minutes post-Stadol indicates effective pain relief and sedation, its intended effect post-op extra food, urine output, or less nausea aren't primary goals. Nurses monitor response, ensuring rest and pain control, critical for recovery in surgical care.
You may also like to solve these questions
During an abdominal assessment, what is the correct sequence of steps for a healthcare provider to follow?
- A. Inspection, percussion, palpation, auscultation
- B. Percussion, auscultation, inspection, palpation
- C. Auscultation, palpation, inspection, percussion
- D. Inspection, auscultation, percussion, palpation
Correct Answer: D
Rationale: During an abdominal assessment, the correct sequence of steps is inspection, auscultation, percussion, and palpation. This sequence is followed to prevent altering bowel sounds. Inspection allows for visual observation, followed by auscultation to listen for bowel sounds without causing disturbance, percussion to assess for tympany or dullness, and finally palpation to feel for any abnormalities or tenderness. Choice A is incorrect because palpation should come after percussion. Choice B is incorrect as auscultation should be performed after inspection. Choice C is incorrect because palpation should be the final step after percussion.
A client with a new diagnosis of type 1 diabetes mellitus is being taught by a nurse. Which of the following statements should the nurse include in the teaching?
- A. You can still eat sugar, but you must count it in your carbohydrate count for the day.
- B. You need to avoid all forms of sugar to keep your blood glucose levels under control.
- C. You can eat unlimited amounts of proteins and fats since they do not affect blood glucose levels.
- D. You will need to take an oral hypoglycemic agent every day to manage your blood glucose levels.
Correct Answer: A
Rationale: The correct statement to include in teaching a client with type 1 diabetes mellitus is that they can still eat sugar, but they must count it in their carbohydrate intake for the day. This is important because clients with type 1 diabetes need to manage their blood glucose levels by calculating their carbohydrate intake, including sugars. Choice B is incorrect because total avoidance of sugar is not necessary, but monitoring and including it in the carbohydrate count is essential. Choice C is incorrect as proteins and fats can also affect blood glucose levels and should be consumed in moderation. Choice D is incorrect since oral hypoglycemic agents are not used in type 1 diabetes mellitus, as insulin replacement therapy is the mainstay of treatment.
Which of the following is TRUE about temperature?
- A. The highest temperature usually occurs later in a day, around 8 P.M to 12 M.N
- B. The lowest temperature is usually in the Afternoon, Around 12 P.M
- C. Thyroxin decreases body temperature
- D. Elderly people are risk for hyperthermia due to the absence of fats, Decreased thermoregulatory control and sedentary lifestyle.
Correct Answer: A
Rationale: Body temperature peaks late day (8 PM-midnight) due to circadian rhythms e.g., higher metabolism. Lowest is early morning (not noon), thyroxin raises temp (not lowers), and elderly risk hypothermia (not hyperthermia) from poor regulation. Nurses monitor this pattern for fever assessment, per physiological norms.
A client with renal calculi is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should increase my intake of calcium-rich foods.
- B. I should decrease my intake of calcium-rich foods.
- C. I should increase my intake of sodium-rich foods.
- D. I should decrease my intake of potassium-rich foods.
Correct Answer: B
Rationale: The correct answer is B because decreasing the intake of calcium-rich foods can help manage and prevent the formation of renal calculi. Excessive calcium intake can contribute to the formation of these stones, so reducing calcium-rich foods is a key dietary modification for individuals with renal calculi. Choice A is incorrect as increasing calcium-rich foods can exacerbate the condition. Choice C is incorrect because increasing sodium-rich foods can lead to more stone formation due to increased calcium excretion. Choice D is incorrect as potassium-rich foods do not directly contribute to the formation of renal calculi.
A client reports difficulty sleeping at night, which interferes with daily functioning. Which intervention should the nurse suggest to this client?
- A. Avoid beverages containing caffeine
- B. Take a sleep medication regularly at bedtime
- C. Watch television for 30 minutes in bed to relax before falling asleep
- D. Advise the client to take several naps during the day
Correct Answer: A
Rationale: The correct answer is A: Avoid beverages containing caffeine. Caffeine is a stimulant that can interfere with sleep, making it difficult for the client to fall asleep at night. Taking sleep medication regularly (choice B) may not address the root cause of the sleep difficulty and can lead to dependency. Watching television in bed (choice C) can actually stimulate the brain and hinder relaxation before sleep. Advising the client to take several naps during the day (choice D) can disrupt the sleep-wake cycle further. Therefore, recommending the avoidance of caffeine-containing beverages is the most appropriate intervention to help the client improve their ability to sleep at night and function better during the day.