Nokea
Which of the following nursing interventions is likely to provide the most relief from the pain associated with renal colic?
- A. Applying moist heat to the flank area.
- B. Administering meperidine (Demerol).
- C. Encouraging high fluid intake.
- D. Maintaining complete bed rest.
Correct Answer: B
Rationale: Meperidine, an opioid, provides the most effective relief for the severe pain of renal colic by directly addressing pain pathways.
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The nurse assesses vital signs on a client who has had epidural anesthesia. For which of the following should the nurse assess next?
- A. Bladder distention.
- B. Headache.
- C. Postoperative pain.
- D. Ability to move the legs.
Correct Answer: A
Rationale: Epidural anesthesia can cause urinary retention due to sensory and motor nerve blockade. Assessing for bladder distention is critical to prevent complications like bladder overdistension.
The nurse caring for a client who is receiving radiation therapy for laryngeal cancer should assess the client for which of the following?
- A. Diarrhea.
- B. Improved energy level.
- C. Dysphagia.
- D. Normal white blood cell count.
Correct Answer: C
Rationale: Dysphagia (difficulty swallowing) is a common side effect of laryngeal radiation due to inflammation and irritation of the throat and esophagus.
The nurse identifies deficient knowledge when the client undergoing induction therapy for leukemia makes which of the following statements?
- A. I will have to pace my activities with rest periods.'
- B. I can't wait to get home to my cat!'
- C. I will use warm saline gargle instead of brushing my teeth.'
- D. I must report a temperature of 100°F.'
Correct Answer: B
Rationale: During leukemia induction therapy, the client is at high risk for infection due to neutropenia. Pets like cats can carry pathogens (e.g., Toxoplasma), and the statement about returning to a cat indicates a knowledge deficit about infection risks. The other statements reflect appropriate self-care measures.
The client's wife asks the nurse whether the I.V. infusion is meeting her husband's nutritional needs because he has vomited several times. The nurse's response should be based on the knowledge that 1 L of 5% dextrose in normal saline solution delivers:
- A. 170 calories.
- B. 250 calories.
- C. 340 calories.
- D. 500 calories.
Correct Answer: A
Rationale: One liter of 5% dextrose provides 50 g of dextrose, yielding approximately 170 calories, insufficient for full nutritional needs.
Which of the following indicates a potential complication of diabetes mellitus?
- A. Inflamed, painful joints.
- B. Blood pressure of 160/100 mm Hg.
- C. Hemoglobin of 11 g/dL.
- D. Fasting blood glucose of 90 mg/dL.
Correct Answer: B
Rationale: Hypertension (160/100 mm Hg) is a common complication of diabetes, contributing to cardiovascular and kidney disease.