Nokea
A patient with second- and third-degree burns. The client is receiving morphine sulfate 15 mg IV. The nurse notes a decrease in bowel sounds and slight abdominal distention.
Which of the following actions, if taken by the nurse, is BEST?
- A. Recommend that the morphine dose be decreased.
- B. Withhold the pain medication.
- C. Administer the medication by another route.
- D. Explore alternative pain management techniques.
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) could indicate a possible impending ileus, this option is not ideal (2) inappropriate (3) inappropriate (4) correct-morphine is drug of choice for burn pain management; when side effect becomes apparent, exploration of alternative pain management techniques such as visualization becomes important
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The nurse is caring for a client with a history of heart failure who is receiving spironolactone (Aldactone) 25 mg PO daily. Which of the following laboratory results would be of GREATest concern to the nurse?
- A. Potassium 5.8 mEq/L.
- B. Sodium 138 mEq/L.
- C. Creatinine 1.2 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: Hyperkalemia (potassium 5.8 mEq/L) is a serious complication of spironolactone, a potassium-sparing diuretic, risking arrhythmias in heart failure. Options B, C, and D are normal: sodium 138 mEq/L, creatinine 1.2 mg/dL, and calcium 9.0 mg/dL do not indicate complications.
The nurse is teaching family members how to correctly transfer a client who has right hemiplegia from the bed to a wheelchair. Which observation indicates that the family understands how to transfer the client?
- A. The wheelchair is placed parallel to the bed on the affected side.
- B. The family members lift the client up by having her place her arms around their necks.
- C. The wheelchair is placed at a 45-degree angle to the bed on the client's unaffected side.
- D. The family members ask for a trapeze bar for the client to use in the transfer.
Correct Answer: C
Rationale: Placing the wheelchair at a 45-degree angle on the unaffected side allows the client to pivot using their stronger left side, ensuring a safe transfer. Affected-side placement or neck lifting is unsafe, and a trapeze is unnecessary.
The nurse is aware that which of the following assessments would be indicative of hypocalcemia?
- A. Constipation.
- B. Depressed reflexes.
- C. Decreased muscle strength.
- D. Positive Trousseau's sign.
Correct Answer: D
Rationale: positive Trousseau's sign is indicative of neuromuscular hyperreflexia associated with hypocalcemia
A middle-aged woman is brought to the emergency room after being raped in her home. The client asks the nurse to call her husband to come to the emergency room. The nurse knows that the most common reaction of significant others to a rape victim is reflected in which of the following statements?
- A. Supportive and helpful to the victim.
- B. Disconnected and apathetic toward the victim.
- C. Frustrated and feeling vulnerable, but denying need for help.
- D. Emotionally distressed and needing assistance.
Correct Answer: D
Rationale: sexual assault by rape is a crisis situation for both victim and family members and friends
A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?
- A. Hypotension, backache, low back pain, fever.
- B. Wet breath sounds, severe shortness of breath.
- C. Chills and fever occurring about an hour after the infusion started.
- D. Urticaria, itching, respiratory distress.
Correct Answer: A
Rationale: signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension