A hospitalized client has a history of depression for which sertraline is prescribed. The client also has a
morphine allergy and a
history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse
choose?
a. Hydrocodone and acetaminophen
b. Hydromorphone...
NUR 1140
A hospitalized client has a history of depression for which sertraline is prescribed. The client also has a
morphine allergy and a
history of alcoholism. After surgery, several opioid analgesics are prescribed. Which one would the nurse
choose?
a. Hydrocodone and acetaminophen
b. Hydromorphone
c. Meperidine
d. Tramadol - ANS: B
Hydromorphone is a good alternative to morphine for moderate to severe pain. The nurse would not
choose the combination with acetaminophen because it contains acetaminophen and the client has a
history of alcoholism. Tramadol would not be used due to
the potential for interactions with the client's sertraline. Meperidine is rarely used and is often
restricted.
The assistive personnel (AP) reports to the registered nurse that a postoperative client has a pulse of 132
beats/min and a blood
pressure of 168/90 mm Hg. What response by the nurse is most appropriate?
a. Ask the AP to repeat the client's vital signs in 15 minutes.
b. Assess the client for pain.
c. Ask the client if something is bothersome.
d. Instruct the AP to reposition the client - ANS: B
The "fight-or-flight" syndrome can occur from sympathetic nervous stimulation due to acute pain.
Symptoms can include nausea, vomiting, diaphoresis, tachycardia, tachypnea, hypertension, and dilated
pupils. Since this client is postoperative, it is reasonable to believe that he or she might be in pain. The
nurse first assesses for pain or discomfort and treats it. If the client is not in pain, the nurse would
conduct further assessments to determine the cause of the abnormal vital signs.
,A client had a recent thromboembolism and must resume work which requires frequent car and plane
travel. What self-care
measure does the nurse teach to reduce the risk of impaired clotting in this client?
a. Get up and walk around at least every 2 hours while traveling.
b. Use a soft toothbrush and an electric razor for safety.
c. Be sure to sit with the legs elevated as much as possible.
d. Increase fiber in the diet so as not to strain to move the bowels. - ANS: A
Clients who are at risk of increased clotting (as evidenced by prior thromboembolic event) can take
several measures to reduce their risk of further problems. One measure is to get up and walk frequently
when sitting for a long period of time. Using a soft toothbrush and an electric razor and needing to
prevent constipation would be important for a client at risk of bleeding. Elevating the legs is not as
beneficial as ambulating.
A nurse is caring for four clients. Which client does the nurse assess first for impaired cognition?
a. A 28-year-old client 2 days post-open cholecystectomy
b. An 88-year-old client 3 days post-hemorrhagic stroke
c. A 32-year-old client with a 20-pack-year history of smoking
d. A 42-year-old client with a serum sodium of 134 mEq/L (134 mmol/L) - ANS: B
There are many risk factors for impaired cognition including advanced age and diseases and disorders
that affect the brain. The
88-year-old client who is recovering from a stroke has two such risk factors and is at highest risk for
impaired cognition. The nurse
assesses this client first. The other clients have a much lower risk of developing impaired cognition.
,A client has urinary incontinence. Which assessment finding indicates that outcomes for a priority
nursing diagnosis have been
met?
a. Client reports satisfaction with undergarments for incontinence.
b. Client reports drinking 8 to 9 glasses of water each day.
c. Skin in perineal area is intact without redness on inspection.
d. Family states that client is more active and socializes more. - ANS: C
Urinary incontinence can lead to skin breakdown and possibility of infection. Skin that is intact without
redness shows that a major goal for this client has been met. Becoming more social is a positive finding
as many adults with incontinence limit their social activities, but this psychosocial outcome is not the
priority over a physical outcome. Being satisfied with undergarments is also not the priority. Drinking
adequate water can sometimes help with incontinence and is important for general health, but is not
directly related to an important goal for this client.
The registered nurse asks the nursing assistant why a cardiac client's morning weight has not yet been
done. The nursing assistant
says, "I'll get to it, what's the big deal?" When deciding how to respond, the nurse considers what
information about weight?
a. Decisions on treatment often depend on the daily weight.
b. The nursing assistant needs to ensure that tasks are done on time.
c. Weight is the most accurate noninvasive indicator of fluid status.
d. A change in weight may indicate the need to change IV fluids. - ANS: C
Weight is the best (noninvasive) indicator of fluid status. Primary health care providers may base
treatment decisions on weight, because the weight reflects fluid balance, but this answer does not
explain why. IV fluid rates or solutions may change for the same reason. The nursing assistant would
perform tasks on a timely basis, but this is not related to information about weight.
The nurse in the emergency department (ED) is caring for four clients. Which client does the nurse assess
for gas exchange
, abnormalities first?
a. Involved in motor vehicle crash, has broken femur.
b. Brought in unconscious by roommate after opioid overdose.
c. Asthmatic client being discharged after bronchodilator therapy.
d. History of COPD, presents to ED after being bitten by a dog. - ANS: B
Opioid medications can cause respiratory depression, so this client is most at risk for gas exchange
problems. Diminished respirations will allow a buildup of carbon dioxide in the blood. The clients with
asthma and COPD have the potential for gas exchange problems but this is not indicated in answer
option as he or she is being discharged. The client with a broken femur does
not have information suggesting gas exchange problems.
The nurse caring for a client with malnutrition assesses which laboratory value as the priority?
a. Albumin
b. Prealbumin
c. Prothrombin time
d. Serum sodium - ANS: B
Both albumin and prealbumin are indicators for nutrition. However, prealbumin changes more rapidly
with decreased nutrition, so it is the better test. Prothrombin time and serum sodium are not directly
related to nutritional status.
A nurse is planning primary prevention measures for community-dwelling adults to prevent visual
impairment. What action by the
nurse will best meet this objective?
a. Provide glaucoma screening.
b. Assess visual acuity.
c. Teach clients about instilling eyedrops.
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