Nokea
What should the nurse assess first in a client with a recent head injury?
- A. Pupil response.
- B. Blood pressure.
- C. Pain level.
- D. Reflexes.
Correct Answer: A
Rationale: Pupil response is assessed first to detect neurological changes, such as increased intracranial pressure, in a head injury.
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The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
- A. Ignore the urge to void.
- B. Force fluids.
- C. Ask for the bedpan.
- D. Ring for assistance to the bathroom.
Correct Answer: D
Rationale: After cystoscopy, the client may feel an urge to void due to bladder irritation. Teaching to ring for assistance ensures safety, as ambulation may be unsteady post-procedure.
For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal?
- A. Pain rating of 0 on a scale of 0 to 10 by the client.
- B. Respiratory rate of 26 breaths/minute.
- C. PaO2 of 70 mm Hg.
- D. None of the above
Correct Answer: A
Rationale: A pain rating of 0 indicates adequate pain control, enabling effective breathing. A respiratory rate of 26 is elevated, and a PaO2 of 70 mm Hg suggests mild hypoxemia, neither confirming pain control.
The client with colon cancer has an abdominal-perineal resection with a colostomy. Which of the following nursing interventions is most appropriate for this client in the postoperative period?
- A. Maintain the client in a semi-Fowler's position.
- B. Assist the client with warm sitz baths.
- C. Administer 30 mL of milk of magnesia to stimulate colostomy activity.
- D. Remove the ostomy pouch as needed so the stoma can be assessed.
Correct Answer: B
Rationale: Appropriate nursing interventions after an abdominal-perineal resection with a colostomy include assisting the client with warm sitz baths three to four times a day to clean the perineal incision. The client will be more comfortable assuming a side-lying position because of the perineal incision. It would be inappropriate to administer milk of magnesia to stimulate colostomy activity. Stool passage will begin as peristalsis returns. It is not necessary to be available to change the ostomy pouch to assess the stoma. The ostomy pouch should be transparent to allow easy observation of the stoma and drainage. CN: Physiological adaptation; CL: Synthesize
The nurse should remind the unlicensed personnel that which of the following is the most important goal in the care of the neutropenic client in isolation?
- A. Listening to the client's feelings of concern.
- B. Completing the client's care in a nonhurried manner.
- C. Performing all of the client's care at one time.
- D. Instructing the client to dispose of tissue after blowing the nose.
Correct Answer: C
Rationale: Performing all care at one time minimizes disruptions and reduces the risk of introducing pathogens to a neutropenic client in isolation. Emotional support, nonhurried care, and tissue disposal are important but secondary to infection prevention.
Allopurinol (Zyloprim), 200 mg/day, is prescribed for the client with renal calculi to take at home. The nurse should teach the client about which the following adverse effects of this medication?
- A. Retinopathy.
- B. Maculopapular rash.
- C. Nasal congestion.
- D. Dizziness.
Correct Answer: B
Rationale: Maculopapular rash is a common adverse effect of allopurinol, requiring monitoring due to potential allergic reactions.