Solutions
A 2-year-old toddler just underwent a tonsillectomy and
adenoidectomy surgery. The postanesthesia care unit (PACU)
nurse is checking on him. What is the best course of action
regarding the developmental care of this child? Correct
Answers allow the parents to come into the room before the
child wakes
A 70-year-old female client had a cholecystectomy four days
ago. The client's daughter tells the nurse, "My mother seems
confused today." Which question would be best for the nurse to
ask in order to assess the client's orientation? Correct Answers
"What day of the week is it?"
A 9-month-old baby is scheduled for heart surgery. When
preparing this patient for surgery, the nurse should consider
which surgical risk associated with infants? Correct Answers
risk for hypothermia and hypothermia
A client age 78 years with diabetes needs to have his toenails
trimmed. It is important for the nurse to do what? Correct
Answers cut the nails straight across
A client asks the nurse which vitamins should be taken daily for
feelings of fatigue, anxiety, and depression 1 week before
menses. Which of the following is the correct response by the
nurse? Correct Answers Vitamin B6
,A client comes to the emergency department complaining of a
shooting pain in his chest. When assessing the client's pain,
which behavioral response would the nurse expect to find?
Correct Answers guarding of the chest area
A client has been diagnosed with a recent myocardial infarction.
What collaborative problem would be the priority for the nurse
to address? Correct Answers PC: Decreased cardiac output
related to cardiac tissue damage
A client in a long-term care facility has become increasingly
unsteady. The nurses are worried that the client will climb out of
bed and fall. Which of the following measures would be a high
priority recommendation for this client? Correct Answers place
a client with a bed that has an alarm
A client is preparing for a fecal occult blood test. What teaching
will the nurse provide regarding vitamin C 3 days before
testing? Correct Answers avoid more than 250 mg
A client is preparing to give a clean-catch specimen. Which
instruction will the nurse provide first? Correct Answers wipe
each side of the urinary meatus with a seperate wipe
A client is prescribed an opioid analgesic. The nurse is teaching
the client a about the need to avoid ingesting alcohol with the
drug to prevent an interaction which would potentiate the effects
of the analgesic. The nurse is describing which event? Correct
Answers Synergism
Explanation:
,When one drug potentiates the effect of another drug when taken
together, synergism occurs. Antagonism occurs when the effects
of one drug are decreased by another drug. Incompatibility
occurs when a drug precipitates from solutions, or becomes
chemically inactive, if mixed with other medications.Tolerance
to a medication occurs when a patient develops a decreased
response to the drug, requiring an increased dosage to achieve
the therapeutic effects.
A client is undergoing conscious sedation for an endoscopy.
When the client becomes overly sedated, which medication does
the nurse anticipate will be required? Correct Answers
Naloxone
Naloxone is a reversal drug, as it is the antagonist for opiates
like morphine. The other medications are inappropriate choices.
A client prescribed pain medication around the clock
experiences pain one hour before the next dose of the pain
medication is due. Which is the most appropriate action by the
nurse? Correct Answers Assess for medication order for
breakthrough pain.
A client reports that he is often unable to retain urine until he
locates a toilet because his mobility is decreased. The nurse
should recognize the characteristics of what type of
incontinence? Correct Answers functional incontinence
functional incontinence when the client is unable to retain urine
for some time after getting an urge to void
, Stress incontinence can result in the loss of small amounts of
urine when intra-abdominal pressure rises
Urge incontinence is the need to void, perceived frequently with
a short-lived ability to sustain control of flow
Total incontinence is the loss of urine without any identifiable
pattern.
A client states that he is pain and requests the ordered pain
medication. When entering the client's room, the client is
laughing with visitors and does not appear to be in pain. What is
the appropriate action by the nurse? Correct Answers
administer the pain medication
A client who has been harassed at her place of work tells the
nurse, "Every time I think of my job, I get a debilitating
headache and have to go lie down to make the pain go away."
Which nursing intervention will the nurse perform to practice
according to the Gate Control Theory? Correct Answers
providing temple massage when head hurts
A client who was a victim of domestic violence for many years
states to the nurse, "I know I should not feel this way, but every
time I think of my former spouse, I get a debilitating headache
and have to go lie down to make the pain go away." Which
nursing intervention reflects practice according to the
Endogenous Opioid Theory? Correct Answers requesting
healthcare provider to order opioid medication
A client with a chest tube wishes to ambulate to the bathroom.
What is the appropriate nursing response? Correct Answers "I
can assist you to the bathroom and back to bed."