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
The nurse treated Mr. Gary's pain before other tasks. This is an example of?
- A. Priority setting
- B. Decision-making
- C. Health literacy
- D. Care coordination
Correct Answer: A
Rationale: Treating pain first is priority setting (A) need-based order, per definition. Decision-making (B) chooses, literacy (C) understanding, coordination (D) organization not priority-specific. A fits the nurse's focus on Mr. Gary's urgency, making it correct.
During postoperative teaching following a hip arthroplasty, which instruction should the nurse include?
- A. Avoid lying on your operative side.
- B. Cross your legs at the ankles only.
- C. Place a pillow between your legs when turning.
- D. Avoid bending your hip more than 120 degrees.
Correct Answer: C
Rationale: The correct instruction for the nurse to include during postoperative teaching following a hip arthroplasty is to 'Place a pillow between your legs when turning.' Placing a pillow between the legs when turning is crucial as it helps prevent dislocation of the hip prosthesis. This position aids in maintaining proper alignment and stability, thereby reducing the risk of complications after hip arthroplasty surgery. Choices A, B, and D are incorrect because they do not directly address the specific action needed to protect the hip prosthesis and prevent complications.
When preparing to insert an NG tube for a client who requires gastric decompression, which of the following actions should the nurse take?
- A. Position the client with the head of the bed elevated to 30° prior to insertion
- B. Measure the tube from the client's nose to the earlobe to the xiphoid process
- C. Lubricate the entire length of the tube with water-soluble lubricant
- D. Instruct the client to cough during insertion
Correct Answer: B
Rationale: Measuring the tube from the client's nose to the earlobe to the xiphoid process ensures the tube is inserted to the correct depth. This measurement helps prevent complications such as tube misplacement or lung insertion. Positioning the client with the head of the bed elevated to 30° is important to facilitate easier insertion but is not the most crucial step. Lubricating the entire length of the tube with water-soluble lubricant is essential for smooth insertion but is not the most critical action. Instructing the client to cough during insertion is not necessary and may lead to unnecessary discomfort.
A client with lactose intolerance is being taught about dietary management by a nurse. Which statement by the client shows an understanding of the teaching?
- A. I should avoid foods that contain lactose.
- B. I should increase my intake of dairy products.
- C. I should avoid foods that contain gluten.
- D. I should increase my intake of high-fiber foods.
Correct Answer: A
Rationale: The correct answer is A: 'I should avoid foods that contain lactose.' Lactose intolerance results from the inability to digest lactose, a sugar found in dairy products. Avoiding foods that contain lactose is essential in managing symptoms like bloating, diarrhea, and abdominal pain. Choice B is incorrect because increasing dairy intake would worsen symptoms. Choice C is incorrect because gluten is unrelated to lactose intolerance. Choice D is incorrect because high-fiber foods are beneficial for other conditions but do not specifically address lactose intolerance.
Which of the following statement is NOT true about standards of care?
- A. Guide nursing practice
- B. Based on evidence
- C. Vary by nurse
- D. Ensure quality
Correct Answer: C
Rationale: Standards guide practice (A), are evidence-based (B), ensure quality (D) 'vary by nurse' (C) isn't true, uniform, per regulation. C's variation contradicts consistency for Mr. Gary's care, making it untrue.