The doctor has ordered a patient-controlled analgesia (PCA) pump for the client with chronic pain. The client asks the nurse if he can become overdosed with pain medication using this machine. The nurse demonstrates understanding of the PCA if she states:
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Solution
Answer B is correct. The client is concerned about overdosing himself. The machine will deliver a set amount as ordered and allow the client to self-administer a small amount of medication. PCA pumps usually are set to lock out the amount of medication that the client can give himself at 5- to 15-minute intervals. Answer A does not address the client’s concerns, answer C is incorrect, and answer D does not address the client’s concerns.
The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
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Solution
Answer B is correct. Skin irritation can occur if the TENS unit is used for prolonged periods of time. To prevent skin irritations, the client should change the location of the electrodes often. Electrocution is not a risk because it uses a battery pack; thus, answer A is incorrect. Answer C is incorrect because the unit should not be used on sensitive areas of the body. Answer D is incorrect because no creams are to be used with the device.
The nurse asked the client if he has an advance directive. The reason for asking the client this question is:
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Solution
Answer B is correct. An advanced directive allows the client to make known his wishes regarding care if he becomes unable to act on his own. Much confusion regarding life-saving measures can occur if the client does not have an advanced directive. Answers A, C, and D are incorrect because the nurse doesn’t need to know about funeral plans and cannot make decisions for the client, and active euthanasia is illegal in most states in the United States.
A client who has chosen to breastfeed complains to the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nipples?
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Solution
Answer B is correct. To decrease the potential for soreness of the nipples, the client should be taught to break the suction before removing the baby from the breast. Answer A is incorrect because feeding the baby during the first 48 hours after delivery will provide colostrum but will not help the soreness of the nipples. Answers C and D are incorrect because applying warm, moist soaks and wearing a support bra will help with engorgement but will not help the nipples.
The nurse is performing an assessment of an elderly client with a total hip repair. Based on this assessment, the nurse decides to medicate the client with an analgesic. Which finding most likely prompted the nurse to decide to administer the analgesic?
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Solution
Answer D is correct. Facial grimace is an indication of pain. The blood pressure in answer A is within normal limits. The client’s inability to concentrate, along with dilated pupils, as stated in answers B and C, may be related to the anesthesia that he received during surgery.
An obstetrical client decides to have an epidural anesthetic to relieve pain during labor. Following administration of the anesthesia, the nurse should:
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Solution
Answer C is correct. Epidural anesthesia involves injecting an anesthetic into the epidural space. If the anesthetic rises above the respiratory center, the client will have impaired breathing; thus, monitoring for respiratory depression is necessary. Answer A, seizure activity, is not likely after an epidural. Answer B, orthostatic hypotension, occurs when the client stands up but is not a monitoring action. The client with an epidural anesthesia must remain flat on her back and should not stand up for 24 hours. Answer D, hematuria, is not related to epidural anesthesia.
The nurse is assessing the client admitted for possible oral cancer. The nurse identifies which of the following as a late-occurring symptom of oral cancer?
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Solution
Answer C is correct. Pain is a late sign of oral cancer. Answers A, B, and D are incorrect because a feeling of warmth, odor, and a flat ulcer in the mouth are all early occurrences of oral cancer.
The nurse is assisting in the care of a patient with diverticulosis. Which of the following assessment findings would necessitate a report to the doctor?
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Solution
Answer D is correct. Low hemoglobin and hematocrit might indicate intestinal bleeding. Answers A, B, and C are normal lab values.
The nurse is caring for the patient’s post-surgical removal of a 6mm oral cancerous lesion. The priority nursing measure would be to:
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Solution
Answer A is correct. Maintaining a patient’s airway is paramount in the post-operative period. This is the priority of nursing care. Answers B, C, and D are applicable but are not the priority. The nurse should instruct the client to perform mouth care using a soft sponge toothette or irrigate the mouth with normal saline. The incision should be kept as dry as possible, and pain should be treated. Pain medications should be administered PRN.
The registered nurse is conducting an in-service for colleagues about peptic ulcers. The nurse would be correct in identifying which of the following as a causative factor?
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Solution
Answer C is correct. H. pylori bacteria has been linked to peptic ulcers. Answers A, B, and D are not typically cultured within the stomach, duodenum, or esophagus, and are not related to the development of peptic ulcers.