Nokea
Which of the following is a priority nursing diagnosis for the diabetic client who is taking insulin and has nausea and vomiting from a viral illness or influenza?
- A. Imbalanced nutrition: Less than body requirements.
- B. Ineffective health maintenance related to ineffective coping skills.
- C. Acute pain.
- D. Activity intolerance.
Correct Answer: A
Rationale: Nausea and vomiting from illness can lead to inadequate food intake, causing imbalanced nutrition, a priority due to the risk of hypoglycemia or ketoacidosis.
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A client who is recovering from a bilateral adrenalectomy has a patient-controlled analgesia (PCA) system with morphine sulfate. Which of the following actions is a priority nursing intervention for the client?
- A. Observing the client at regular intervals for opioid addiction.
- B. Encouraging the client to reduce analgesic use and tolerate the pain.
- C. Evaluating pain control at least every 2 hours.
- D. Increasing the amount of morphine if the client does not administer the medication.
Correct Answer: C
Rationale: Regularly evaluating pain control ensures adequate relief while monitoring for side effects, a priority in PCA management.
Which of the following is the priority for a client in addisonian crisis?
- A. Controlling hypertension.
- B. Preventing irreversible shock.
- C. Preventing infection.
- D. Relieving anxiety.
Correct Answer: B
Rationale: Addisonian crisis is a life-threatening condition requiring urgent intervention to prevent irreversible shock due to adrenal insufficiency.
Which of the following is the best way for the nurse to begin the preoperative interview?
- A. Walk in the client's room and ask, 'Are you Mrs. Smith?'
- B. Walk in the client's room, sit down, and take the client's blood pressure.
- C. Walk in the client's room, sit down, maintain eye contact, and introduce yourself.
- D. Walk in the client's room, and ask the client her name.
Correct Answer: C
Rationale: Introducing oneself while maintaining eye contact and sitting down establishes rapport and trust, creating a therapeutic environment for the interview. This approach prioritizes patient comfort and communication.
The nurse is developing a discharge plan for a client who had a phacoemulsification procedure. Which of the following should the nurse include? Select all that apply.
- A. Teach the client how to instill eye drops.
- B. Instruct the client not to lie on the affected side.
- C. Remind the client that a reduction of vision is normal.
- D. Provide the client with an eye patch for the affected eye.
- E. Educate the client to avoid bending at the waist.
Correct Answer: A,B,D,E
Rationale: Post-phacoemulsification care includes teaching eye drop instillation, avoiding lying on the affected side, using an eye patch for protection, and avoiding bending to prevent pressure increase. Reduced vision is not normal and requires evaluation.
Which of the following is contraindicated for a client diagnosed with disseminated intravascular coagulation (DIC)?
- A. Treating the underlying cause.
- B. Administering heparin.
- C. Administering warfarin sodium (Coumadin).
- D. Replacing depleted blood products.
Correct Answer: C
Rationale: Warfarin is contraindicated in DIC because it further inhibits clotting factors, worsening bleeding. Treating the underlying cause, administering heparin (to stop clotting), and replacing blood products are standard treatments to manage DIC.