Question

1. A nurse is caring for a client who is receiving epidural analgesia. Which of the following assessment findings is the nurse's priority?

1. Hypotension
2. Bladder distention
3. Hypoactive bowel sounds
4. Weakness to lower extremities
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2. A nurse is preparing a teaching plan for a client who has mucositis related to chemotherapy treatment. Which of the following instructions should the nurse include?

1. "Floss your teeth gently following each meal."
2. "Brush your teeth for 60 seconds twice daily."
3. "Rinse your mouth with hydrogen peroxide."
4. "Wear your dentures only during meals."

3.    A nurse is caring for a client who has a duodenal ulcer. Which of the following actions should the nurse take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) EXHIBIT

1. Restrict the client's fluid intake to 1,000 ml day.
2. Infuse packed RBCS.
3. offer a snack before bedtime.
4. Administer the client's naproxen prescription.

4. A nurse is caring for a client who sustained a spinal cord injury in a diving accident. Which of the following actions should the nurse takE
   1. Assess the client's neurological status every & hr.
   2. Log roll the client every 4 hr.
   3. Provide the client with a low-fiber diet.
   4. Monitor urine output hourly.

Answer 1

1.Option A is correct.Nurse first priority is to assess the hypotension when a patient is receiving epidural injection.Blood pressure should be checked every 5 minutes.

Option B Is incorrect.Bladder assessment is needed but not first priority.

Option C is incorrect because there is no need for nurse to check hypoactive bowel sounds.

Option D is incorrect because weakness to lower extremity is rare complication of epidural analgesic.

Option E is incorrect.

2.option B is correct.The nurse should educate the patient to brush the teeth twice daily for 60 second.

Option A is incorrect because flossing the teeth in each meal is not needed.Flossing once in a day is fine.

Option C is incorrect because rinse mouth with baking soda.

Option D is not correct because don't wear dentures during the meals

3 Option C is correct.In duodenal ulcer the patient should eat smaller meals before going to the bed.

Option A is incorrect because don't restrict the fluid intake to 1 litre.

Option B is incorrect because infused Rbc pack is used in acute upper gastrointestinal bleeding in peptic ulcer

Option D is incorrect because administer naproxen is needed during the pain due to ulcers.

4.Option A is correct.Asess the patient's neurological status every hour in spinal cord injury.

Option B Is incorrect because log rolling is done to test hip pathology

Option C is incorrect because providing the client with low fiber diet is not a priority.

Option D is incorrect because in spinal cord injury the bladder sphincter is absent leading to urinary retention so no need of hourly monitoring of urine needed .