Nokea
Thirty minutes after receiving IV morphine, a postoperative client continues to rate pain as 7 on a 10-point scale. Which action should the PN implement first?
- A. Call healthcare provider to request a different analgesic
- B. Determine when morphine can be given again
- C. Implement complementary pain relief methods
- D. Observe dressing to determine the presence of bleeding
Correct Answer: C
Rationale: The most appropriate action for the PN to implement first is to implement complementary pain relief methods. This includes repositioning the client, applying heat or cold packs, or using relaxation techniques. These strategies can provide additional pain relief before the next dose of medication is due or before seeking further instructions from the healthcare provider. Calling the healthcare provider immediately to request a different analgesic (Choice A) may not be necessary at this moment since other non-pharmacological methods can be attempted first. Determining when morphine can be given again (Choice B) is important but addressing the client's immediate pain relief takes precedence. Observing the dressing for bleeding (Choice D) is important but not the first priority when the client is experiencing unrelieved pain.
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What is the first action a healthcare professional should take when a patient's nasogastric (NG) tube becomes clogged?
- A. Flush the tube with water
- B. Reposition the patient
- C. Attempt to aspirate the clog with a syringe
- D. Administer a medication to dissolve the clog
Correct Answer: C
Rationale: When a patient's nasogastric (NG) tube becomes clogged, the first action to take is to attempt to aspirate the clog with a syringe. This is a standard and initial step to clear the blockage in the tube. Flushing the tube with water (Choice A) may not address the specific clog; repositioning the patient (Choice B) is not directly related to clearing the tube. Administering a medication to dissolve the clog (Choice D) should only be considered after simpler methods like aspiration have been attempted.
Patients are coming into the emergency room as a result of an apartment house fire. You are examining a patient who is in distress but has no visible burn marks. You suspect that she is suffering from inhalation burns. Which of the following signs would NOT be associated with inhalation burns?
- A. Singed nasal hairs
- B. Conjunctivitis
- C. Hoarseness
- D. Clear sputum
Correct Answer: D
Rationale: Clear sputum would not be associated with inhalation burns. Inhalation burns typically present with symptoms like singed nasal hairs, conjunctivitis, hoarseness, and possibly soot in sputum due to smoke inhalation. Clear sputum suggests that there is no significant inflammation or injury to the respiratory tract, which is not consistent with the typical findings in inhalation burns. The other choices are associated with inhalation burns: singed nasal hairs can occur due to exposure to hot air or gases, conjunctivitis can result from irritating substances in smoke, and hoarseness can be due to airway irritation.
When caring for a client with colostomy, which topical skin preparation should the PN apply around the stoma?
- A. Antiseptic cream
- B. Petroleum jelly
- C. Cornstarch
- D. Stomadhesive
Correct Answer: D
Rationale: The correct answer is 'Stomadhesive.' Stomadhesive is a protective barrier used around the stoma to prevent skin irritation and to secure the colostomy bag. This preparation helps to maintain skin integrity and prevent complications such as skin breakdown. Antiseptic cream (Choice A) is not typically used around the stoma as it can irritate the skin. Petroleum jelly (Choice B) is also not recommended as it can interfere with the adhesive properties of the colostomy appliance. Cornstarch (Choice C) is not suitable for application around the stoma as it can promote moisture and lead to skin irritation.
While providing oral care for a client who is unconscious, the nurse positions the client laterally and uses a basin to collect secretions. Which intervention is best for the nurse to implement?
- A. Swab the oral cavity with a washcloth
- B. Use oral swabs with normal saline
- C. Provide a Yankauer tip for oral suction
- D. Support the head with a small pillow
Correct Answer: B
Rationale: Using oral swabs with normal saline is the best intervention in this scenario as it effectively cleans the oral cavity without causing irritation or dryness, which is crucial for an unconscious client. Swabbing the oral cavity with a washcloth may not provide thorough cleaning, and it can potentially cause irritation. Providing a Yankauer tip for oral suction is not necessary unless there are excessive secretions that need to be suctioned. Supporting the head with a small pillow, although important for comfort, is not directly related to oral care in an unconscious client.
The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?
- A. Document the lacerations in the client's record
- B. Report findings to the supervisor for referral to adult protective services
- C. Ask the daughter who has been taking care of the client on a daily basis
- D. Apply dry dressings after cleansing the wounds
Correct Answer: B
Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.