Nokea
When caring for a client with pain, which of the following is essential throughout the client’s care?
- A. Giving assurance that pain management is a nursing and agency priority.
- B. Giving assurance that pain relief will be immediate and effective.
- C. Giving assurance that pain relief will be permanent.
- D. Giving assurance that pain has a psychological basis and can be easily managed.
Correct Answer: A
Rationale: The correct answer is A because ensuring that pain management is prioritized by both nursing staff and the healthcare facility is crucial for consistent and effective care.
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What does weight gain during the postoperative period indicate?
- A. Urine retention
- B. Healthy recovery
- C. Paralytic ileus
- D. Hypoxia
Correct Answer: C
Rationale: The correct answer is C because weight gain can indicate fluid retention due to paralytic ileus.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit?
- A. The client who has been NPO since midnight for endoscopy
- B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL
- C. The client who has end-stage renal failure and is scheduled for dialysis today
- D. The client who has gastroenteritis and is febrile
Correct Answer: D
Rationale: Step 1: The client with gastroenteritis is at risk for fluid volume deficit due to vomiting and diarrhea, leading to loss of fluids.
Step 2: Febrile state increases fluid loss through sweating.
Step 3: Combining gastroenteritis and fever exacerbates fluid loss, making this client at high risk.
Step 4: Clients A, B, and C do not have immediate factors contributing to fluid volume deficit as evident from their conditions.
Summary: Client D is at risk due to gastroenteritis and fever causing significant fluid loss. Clients A, B, and C do not have conditions directly leading to fluid deficit.
Which nursing actions would demonstrate the nurse’s understanding of the concept of providing safe care without using restraints (select all that apply)?
- A. Placing patients with fall risk in low beds.
- B. Making hourly rounds on patients to assess for pain and toileting needs.
- C. Applying a jacket vest loosely so the patient can turn but cannot climb out of bed.
- D. Placing a disruptive patient near the nurses’ station in a chair with a seat belt.
Correct Answer: B
Rationale: Low beds, frequent checks, and strategic placement reduce risks without resorting to physical restraints.
A physician is monitoring intravenous fluids for someone who is currently being treated for metabolic acidosis. The physician monitors his signs and symptoms typical of metabolic acidosis which include:
- A. Elevated blood pressure,bradycardia,elevated respiratory rate and muscle twitching.
- B. Hypotension altered heart rate elevated respiratory rate and muscle weakness.
- C. Hypertension tachycardia slowed respiratory rate and muscle spasms.
- D. Hypotension hypoxia irritability and paresthesia.
Correct Answer: B
Rationale: The correct answer is Hypotension, altered heart rate, elevated respiratory rate, and muscle weakness (B). Metabolic acidosis causes the body to compensate by increasing respiratory rate to blow off CO2, leading to hyperventilation. Other symptoms include hypotension, altered heart rate, and muscle weakness due to electrolyte imbalances.
A client has periodic outbreaks of cold sores long after the initial infection of herpes simplex virus. Why does this occur?
- A. The client has low resistance.
- B. The client has not received proper treatment.
- C. The viruses are dormant in the client.
- D. The viruses are immune to the therapy.
Correct Answer: C
Rationale: The correct answer is C because the herpes simplex virus can become dormant in nerve cells and reactivate periodically, leading to recurrent outbreaks.