Nokea
Which information about the client's use of a patient-controlled analgesia (PCA) pump is most important to communicate to the staff on the next shift?
- A. Name of the client's physician
- B. Purpose for using the pump
- C. Number of doses administered
- D. The client's need for further teaching
Correct Answer: C
Rationale: The number of doses administered is critical for monitoring pain control and preventing overdose.
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After the coronary arteriogram, the nurse must keep the client flat in bed with the affected leg in which position?
- A. Extended
- B. Flexed
- C. Abducted
- D. Adducted
Correct Answer: A
Rationale: Keeping the leg extended prevents bleeding or hematoma at the femoral artery puncture site by minimizing movement.
An adult client with peripheral vascular disease tells the nurse he is afraid his left leg is not improving and may need to be amputated. How should the nurse respond?
- A. You and your wife should discuss your feelings before surgery.'
- B. You sound concerned about your leg and possible surgery.'
- C. It is better to have an amputation when the ulcers are not improving.'
- D. You don't need to be afraid of surgery.'
Correct Answer: B
Rationale: Reflecting the client’s concern encourages open communication and validates his feelings, promoting therapeutic dialogue.
Which side effects are most closely associated with the use of nitroglycerin tablets? Select all that apply.
- A. Headache
- B. Backache
- C. Headache
- D. Jaundice
- E. Dizziness
- F. Pallor
Correct Answer: A,E
Rationale: Nitroglycerin causes vasodilation, leading to headache (due to cerebral vasodilation) and dizziness (due to hypotension). Backache, jaundice, and pallor are not typical.
A client has an elevated AST 24 hours following chest pain and shortness of breath. This is suggestive of which of the following?
- A. Gallbladder disease
- B. Liver disease
- C. Myocardial infarction
- D. Skeletal muscle injury
Correct Answer: C
Rationale: AST is an enzyme released in response to tissue damage. The symptoms of chest pain and shortness of breath, along with elevated AST 24 hours later, are suggestive of myocardial infarction. AST rises after a myocardial infarction but may also rise with liver damage or skeletal muscle injury. Gallbladder disease typically presents with pain in the right scapula region and would not have an elevated AST.
Having heard the observer's comment, which statement by the nurse would be most helpful for an untrained individual to remember if a trained individual is not present?
- A. An untrained person can always stay with the victim until help arrives.
- B. Do not worry about compressions; just breathe regularly in the mouth.
- C. Begin chest compressions in the center of the chest pressing down 2 inches (5 cm).
- D. Place the client flat and elevate the feet to promote circulation.
Correct Answer: C
Rationale: Untrained individuals can perform compression-only CPR, pressing 2 inches deep at 100-120 per minute.