Nokea
Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following as an appropriate client outcome?
- A. The client maintains bed rest.
- B. There is redness and swelling at the aspiration site.
- C. The client requests morphine sulfate for pain.
- D. There is no bleeding at the aspiration site.
Correct Answer: D
Rationale: A successful outcome 24 hours after bone marrow aspiration is no bleeding at the site, indicating proper healing and no complications. Bed rest is not required, redness/swelling suggests infection, and morphine requests indicate uncontrolled pain, which is not expected.
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A nurse is admitting a client who has been admitted with a diagnosis of upper GI bleeding to the hospital. The nurse should assess the client for which of the following? Select all that apply.
- A. Dry, flushed skin.
- B. Decreased urine output.
- C. Tachycardia.
- D. Widening pulse pressure.
- E. Rapid respirations.
- F. Thirst.
Correct Answer: A,B,C,E,F
Rationale: Upper GI bleeding can lead to hypovolemia, causing dry, flushed skin, decreased urine output, tachycardia, rapid respirations, and thirst. Widening pulse pressure is not typically associated with hypovolemia.
A client is admitted with a 6.5-cm thoracic aneurysm. The nurse records fi ndings from the initial assessment in the client’s chart, as shown below. At 10:30 a.m., the client complains of sharp midchest pain after having a bowel movement. What should the nurse do first?
- A. Assess the client’s vital signs.
- B. Administer a bolus of lactated Ringer’s solution.
- C. Assess the client’s neurologic status.
- D. Contact the physician.
Correct Answer: A
Rationale: The size of the thoracic aneurysm is rather large, so the nurse should anticipate rupture. A sudden incidence of pain may indicate leakage or rupture. The blood pressure and heart rate will provide useful information in assessing for hypovolemic shock. The nurse needs more data before initiating other interventions. After assessment of vital signs, neurologic status, and pain, the nurse can then contact the physician. Administering lactated Ringer’s solution would require a physician’s order
What therapeutic outcome does the nurse expect for a client who has received a premedication of glycopyrrolate (Robinul)?
- A. Increased heart rate.
- B. Increased respiratory rate.
- C. Decreased secretions.
- D. Decreased amnesia.
Correct Answer: C
Rationale: Glycopyrrolate is an anticholinergic that reduces salivary and respiratory secretions, improving airway management during surgery.
The nurse observes that an older female has small to moderate, distended and tortuous veins running along the inner aspect of her lower legs. The nurse should:
- A. Apply a half-leg pneumatic compression device
- B. Suggest the client contact her physician
- C. Assess the client for foot ulcers
- D. Encourage the client to avoid standing in one position for long periods of time
Correct Answer: D
Rationale: Distended, tortuous veins suggest varic varicose veins. Avoiding prolonged standing reduces venous pooling and symptom progression. Applying compression devices requires a prescription, contacting a physician is premature, and foot ulcers are not indicated by the description.
The nurse using healing touch affects a client's pain primarily through:
- A. Energy fields.
- B. Touch therapy.
- C. Massage.
- D. Hypnosis.
Correct Answer: A
Rationale: Healing touch primarily uses energy fields to promote relaxation and pain relief, distinct from massage, physical touch therapy, or hypnosis.