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A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?
- A. Assess for pain relief.
- B. Monitor for respiratory depression.
- C. Assess the infusion site for complications.
- D. Increase the dosage if the client reports more pain.
Correct Answer: B
Rationale: Correct answer: Before administering morphine sulfate, the nurse should monitor for respiratory depression as it is a significant side effect of this medication. Assessing for pain relief (Choice A) is important but not a pre-administration assessment. Checking the infusion site for complications (Choice C) is relevant for IV medications, not specifically for morphine sulfate. Increasing the dosage if the client reports more pain (Choice D) is not appropriate without further assessment and medical orders.
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A healthcare provider is assessing a patient with dehydration. Which finding indicates the patient's condition is worsening?
- A. Dry mucous membranes.
- B. Tachycardia and low blood pressure.
- C. Bradycardia and shallow respirations.
- D. Clear lung sounds.
Correct Answer: B
Rationale: Tachycardia and low blood pressure are indicative of worsening dehydration in a patient. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased intravascular volume, while low blood pressure reflects inadequate perfusion due to decreased fluid levels. Bradycardia and shallow respirations are not typical findings in worsening dehydration, and clear lung sounds do not directly correlate with the severity of dehydration.
The nurse is performing hand hygiene before assisting a healthcare provider with insertion of a chest tube. While washing hands, the nurse touches the sink. Which action will the nurse take next?
- A. Repeat handwashing using antiseptic soap.
- B. Inform the healthcare provider and recruit another nurse to assist.
- C. Extend the handwashing procedure to 5 minutes.
- D. Rinse and dry hands and begin assisting the healthcare provider.
Correct Answer: A
Rationale: The correct answer is A. The sink is considered a contaminated area. When hand hygiene is compromised during the process, it is essential to repeat handwashing using antiseptic soap to ensure proper hygiene. Choice B is incorrect because the situation can be managed by proper handwashing. Choice C is incorrect as extending the handwashing procedure to 5 minutes is not necessary in this scenario. Choice D is incorrect as the hands need to be properly cleaned before assisting the healthcare provider.
A patient recovering from a stroke has difficulty swallowing. Which action should the nurse prioritize?
- A. Begin feeding the patient soft solids.
- B. Place the patient on NPO (nothing by mouth) status.
- C. Provide ice chips to help soothe the throat.
- D. Start the patient on a clear liquid diet.
Correct Answer: B
Rationale: The correct answer is to place the patient on NPO (nothing by mouth) status. Patients recovering from a stroke with difficulty swallowing are at high risk for aspiration, which can lead to serious complications like aspiration pneumonia. Therefore, the priority is to keep the patient on NPO until a thorough evaluation by a healthcare provider is completed. Choice A is incorrect as feeding the patient soft solids can increase the risk of aspiration. Choice C is incorrect as providing ice chips may further compromise swallowing safety. Choice D is incorrect as starting the patient on a clear liquid diet can also increase the risk of aspiration in this scenario.
What is the recommended procedure for a healthcare professional to follow when applying sterile gloves?
- A. Use non-sterile gloves first, followed by sterile gloves.
- B. Put on sterile gloves, then gown.
- C. Apply gloves after donning a mask.
- D. Apply gloves before touching any sterile equipment.
Correct Answer: D
Rationale: The correct procedure for applying sterile gloves is to do so before touching any sterile equipment or surfaces. This helps maintain the sterility of the gloves. Choices A, B, and C are incorrect because they suggest incorrect sequences that may compromise the sterility of the gloves. Using non-sterile gloves first can introduce contamination, putting on gloves before a gown can lead to contamination of the gloves during gowning, and applying gloves after donning a mask can risk contamination of the gloves from the mask.
A nurse suspects a colleague of diverting narcotics. What is the nurse's first course of action?
- A. Confront the colleague directly about the suspicion.
- B. Report the suspicion to the nurse manager.
- C. Ignore the situation unless there is clear evidence.
- D. Keep a record of the colleague's actions for future reference.
Correct Answer: B
Rationale: The correct first course of action for a nurse suspecting a colleague of diverting narcotics is to report the suspicion to the nurse manager. Confronting the colleague directly may not be safe and could compromise the investigation. Ignoring the situation is not appropriate as it can pose risks to patient safety. Keeping a record of the colleague's actions is not the primary action to take when drug diversion is suspected; reporting to the nurse manager is crucial for proper investigation and ensuring patient safety.