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Two days after surgery, a client continues to take hydrocodone 7.5 mg and acetaminophen 500 mg (Lortab 7.5/500). What should the nurse ask the client before administering the pain medication?
- A. œWhere is your pain located?'
- B. œHave you emptied your bladder?'
- C. œHow long has it been since your last dose?'
- D. œIs your pain better than before you had surgery?'
Correct Answer: C
Rationale: Asking about the time since the last dose ensures safe administration, preventing overdose or toxicity, as hydrocodone has a specific dosing interval.
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Which of the following measures would most likely be successful in reducing pleuritic chest pain in a client with pneumonia?
- A. Encourage the client to breathe shallowly.
- B. Have the client practice abdominal breathing.
- C. Offer the client inceptive spirit.
- D. Teach the client to splint the rib cage when coughing.
Correct Answer: D
Rationale: Splinting the rib cage during coughing stabilizes the chest, reducing pleuritic pain. Shallow breathing may worsen atelectasis. Abdominal breathing aids ventilation but not pain. 'Inceptive spirit' is likely a typo for incentive spirometry, which promotes lung expansion but not direct pain relief.
What is the nurse's best action for a client with a C6 spinal cord injury?
- A. Assess respiratory status.
- B. Check bladder function.
- C. Monitor skin integrity.
- D. Evaluate motor strength.
Correct Answer: A
Rationale: Assessing respiratory status is the priority due to potential diaphragmatic impairment in a C6 injury.
The nurse is developing a plan to teach a client deep-breathing exercises to expand collapsed alveoli and prevent postoperative atelectasis and pneumonia. Which of the following steps should be included? Select all that apply.
- A. Splint or support the incision to promote maximal comfort.
- B. Inhale slowly through the nostrils; exhale through pursed lips.
- C. Hold the breath for about 5 seconds to expand the alveoli.
- D. Repeat this breathing method 5 to 10 times hourly.
- E. Close one nostril while inhaling.
Correct Answer: A,B,C,D
Rationale: Splinting the incision (A), slow nasal inhalation with pursed-lip exhalation (B), holding the breath (C), and repeating 5-10 times hourly (D) are correct steps for deep-breathing exercises to prevent atelectasis. Closing one nostril (E) is not part of this technique.
A client is scheduled for a renal ultrasound. The nurse explains that:
- A. Contrast dye is used.
- B. No preparation is needed.
- C. Fasting is required.
- D. A sedative is given.
Correct Answer: B
Rationale: Renal ultrasound is non-invasive and requires no special preparation.
The nurse is assessing a client with chronic hepatitis B who is receiving Lamivudine (Epivir). What information is most important to communicate to the physician?
- A. The client's daily record indicates a 3 kg weight loss in 2 days.
- B. The client is complaining of nausea.
- C. The client has a temperature of 99°F orally.
- D. The client has fatigue.
Correct Answer: A
Rationale: A 3 kg weight loss in 2 days (A) is significant and may indicate worsening liver function or fluid loss, requiring urgent physician attention. Nausea (B), low-grade fever (C), and fatigue (D) are common but less critical.