intro to adult health unit 2-- Review questions

The nurse is instructing a client about receiving patient-controlled analgesia to control postoperative pain. What comment by the client indicates that further instruction is needed? a) "that's great that overdosing can't happen" b) "it will keep my pain at a pretty consistent level" c) "I feel a lot less nervous because I can control my own pain" d) "I'm glad I can give myself some medication and not have to wait for the nurse to give me something"

"That's great that overdosing can't happen"

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: a) place a bed alarm device on the bed b) place patient in a belt restraint c) provide one-on-one observation of the patient d) apply wrist restraints

a) place a bed alarm device on the bed

The home health care nurse is caring for a client with cancer who is complaining of acute pain. The most appropriate determination of the client's pain should include which assessment? a) the client's pain rating b) nonverbal cues from the client c) nurse's impression of the client's pain d) pain relief after appropriate nursing intervention

a) the client's pain rating client's self-report is critical component of pain assessment

The nurse is caring for a postoperative client who is receiving demand-dose hydromorphone via a patient-controlled analgesia (PCA) pump for pain control. The nurse enters the client's room and finds the client drowsy and records the following vital signs: temp 97.2 orally, pulse 52 beats per minute, blood pressure 101/58 mmHG, respiratory rate 11 breaths per minute, and SpO2 of 93% on 3 liters of oxygen via nasal cannula. Which action should nurse take next? a) document findings b) attempt to arouse the client c) contact health care provider d) check medication administration history on the PCA pump

b) attempt to arouse the client NEEDS to see how sedated patient is first

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? a) check the client's carotid pulse b) encourage the client to get to the toilet c) in a loud voice, call for help d) gently lower the client to the floor

d) gently lower the client to the floor

The nursing assessment of a 78-year-old woman reveals orthostatic hypotension, weakness on the left side, and fear of falling. On the basis of the patient's data, which one of the following nursing diagnoses indicates an understanding of the assessment findings? a) activity intolerance b) impaired bed mobility c) acute pain d) risk for falls

d) risk for falls