Nokea
Which of the following nursing interventions would best accomplish the goal of preventing atelectasis and pneumonia in a postoperative client?
- A. Administer oxygen therapy as needed to maintain adequate oxygenation.
- B. Offer pain medication before having the client deep-breathe and use incentive spirometry.
- C. Encourage the client to cough, deep-breathe, and turn in bed and to 2,000 mL every 24 hours.
- D. Encourage the client to cough, deep-breathe, and turn in bed every 2 hours.
Correct Answer: B
Rationale: Pain control is essential to enable effective deep breathing and incentive spirometry, which prevent atelectasis and pneumonia by promoting lung expansion. Oxygen and fluid intake are supportive but secondary.
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Which of the following theories of pain are you utilizing when you recognize the fact that some of the factors that open this 'gate' to pain are low endorphins and anxiety and that some of the factors that close this 'gate' to pain are decreased anxiety and fear?
- A. Moritz Schiff's theory of pain
- B. The Intensive Theory of Pain
- C. Melzack and Wall's theory of pain
- D. The Specificity Theory of Pain
Correct Answer: C
Rationale: Melzack and Wall's Gate Control Theory posits that pain perception is modulated by factors like anxiety (opening the gate) and reduced anxiety or endorphins (closing the gate).
The antidote for heparin is:
- A. Vitamin K.
- B. Warfarin (Coumadin).
- C. Thrombin.
- D. Protamine sulfate.
Correct Answer: D
Rationale: Protamine sulfate rapidly reverses heparin's anticoagulant effects by binding to it, neutralizing its activity.
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
A client with a history of chronic kidney disease is prescribed sevelamer (Renagel). The nurse should explain that this medication works by:
- A. Reducing blood pressure.
- B. Binding phosphate in the gut.
- C. Increasing urine output.
- D. Decreasing blood glucose.
Correct Answer: B
Rationale: Sevelamer binds phosphate in the gut, reducing serum phosphate levels in chronic kidney disease.
The nurse is teaching a client who is taking cyclosporine after renal transplant about medication information. The nurse should tell the client to be especially alert for which problem?
- A. Hair loss
- B. Weight loss
- C. Hypotension
- D. Signs of infection
Correct Answer: D
Rationale: Cyclosporine is an immunosuppressant medication used to prevent transplant rejection. The client should be especially alert for signs and symptoms of infection while taking this medication and report them to the primary health care provider if experienced. The client is also taught about other side/adverse effects of the medication, including hypertension, increased facial hair, tremors, gingival hyperplasia, and gastrointestinal complaints. Some weight loss may occur, but this is not as significant as the onset of an infection.