Nokea
When giving discharge instructions to the client with vasospastic disorder (Raynaud's phenomenon), the nurse should explain that the expected outcome is a total of the symptoms by:
- A. Decreasing the influence of the sympathetic nervous system on the tissues in the hands and feet
- B. Decreasing the pain by producing analgesia
- C. Increasing the blood supply to the affected area
- D. Increasing monoamine oxidase
Correct Answer: C
Rationale: The expected outcome in Raynaud's is increased blood supply to the affected areas by reducing vasospasm, alleviating symptoms like numbness and pallor. Sympathetic nervous system influence, analgesia, and monoamine oxidase are not directly targeted.
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Which of the following is normal for a client during the icteric phase of viral hepatitis?
- A. Tarry stools.
- B. Yellowed sclera.
- C. Shortness of breath.
- D. Light, frothy urine.
Correct Answer: B
Rationale: The icteric phase involves jaundice, causing yellowed sclera (B) due to bilirubin buildup. Tarry stools (A) indicate bleeding, not typical. Shortness of breath (C) and frothy urine (D) are unrelated.
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
- A. Check that the family is comfortable.
- B. Assess vital signs following the use of morphine.
- C. Dim the lights in the room.
- D. Increase nasal oxygen from 2 to 3 L.
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
The nurse is reviewing a client's preoperative checklist and notes the client has not voided in the last 6 hours. The nurse should:
- A. Insert a urinary catheter.
- B. Encourage the client to void before transport.
- C. Notify the anesthesiologist.
- D. Document the finding and proceed.
Correct Answer: B
Rationale: Encouraging the client to void prevents bladder distention during surgery and reduces the need for catheterization, which carries infection risks.
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.
What diet should be implemented for a client who is in the early stages of cirrhosis?
- A. High-calorie, high-carbohydrate.
- B. High-protein, low-fat.
- C. Low-fat, low-protein.
- D. High-carbohydrate, low-sodium.
Correct Answer: A
Rationale: A high-calorie, high-carbohydrate diet (A) supports energy needs in early cirrhosis. High-protein (B) may worsen encephalopathy. Low-fat, low-protein (C) is too restrictive. Low-sodium (D) is relevant for ascites, not early cirrhosis.