Nokea
A nurse is receiving a provider's prescription by telephone for morphine for a client who is reporting moderate to severe pain. Which of the following nursing actions are appropriate? Select all.
- A. Repeat the details of the prescription back to the provider
- B. Have another nurse listen to the telephone prescription
- C. Obtain the prescriber's signature on the prescription within 24hrs
- D. Decline the verbal prescription because it is not an emergency situation
- E. Tell the charge nurse that the provider has prescribed morphine by telephone
Correct Answer: A, B, C
Rationale: The correct choices are A, B, and C. A nurse should repeat the prescription back to the provider to ensure accurate communication and prevent errors. Having another nurse listen to the prescription can provide an additional check for accuracy and clarity. Obtaining the prescriber's signature on the prescription within 24 hours is necessary for documentation and legal purposes. Choice D should be ruled out as it is not appropriate to decline a valid prescription for pain medication in a timely manner. Choice E does not address the immediate need to confirm and document the prescription accurately.
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A nurse educator is teaching a module on safe med administration to newly hired nurses. Which of the following statements by the newly hired nurse indicate understanding of the nurse's responsibility when implementing med therapy? Select all.
- A. I will observe for med side effects.
- B. I will monitor for therapeutic effects.
- C. I will prescribe the appropriate dose.
- D. I will change the dose if adverse effects occur.
- E. I will refuse to give a med if I believe it is unsafe.
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. A nurse's responsibility in implementing medication therapy includes observing for side effects (A), monitoring for therapeutic effects (B), and refusing to give a medication if they believe it is unsafe (E).
A - Observing for side effects is crucial in ensuring patient safety and prompt intervention if adverse reactions occur.
B - Monitoring for therapeutic effects helps assess the effectiveness of the medication in achieving the desired outcomes for the patient's condition.
E - Refusing to give a medication if the nurse believes it is unsafe demonstrates advocacy for the patient's well-being and adherence to the principles of safe medication administration.
Choices C and D are incorrect because nurses should not prescribe or change medication doses without proper authorization from a prescribing healthcare provider. It is beyond the scope of a nurse's role.
In summary, the correct answers focus on patient safety, monitoring effectiveness, and advocating for the patient's best interest, while the incorrect choices involve actions outside the nurse's scope
A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home? Select all.
- A. Family members who smoke must be at least 10 ft from the client when the oxygen is in use
- B. Nail polish should not be used near a client who is receiving oxygen
- C. A 'No smoking' sign should be placed on the front door
- D. Cotton bedding & clothing should be replaced with items made from wool
- E. A fire extinguisher should be readily available in the home
Correct Answer: B, C, E
Rationale: The correct answers are B, C, and E.
B: Nail polish should not be used near a client who is receiving oxygen to prevent a fire hazard as it is flammable.
C: A 'No smoking' sign should be placed on the front door to remind visitors not to smoke near the oxygen source.
E: A fire extinguisher should be readily available in the home to handle any fire emergencies related to oxygen use.
Incorrect choices:
A: Family members who smoke must be at least 10 ft from the client when the oxygen is in use is not as crucial as preventing ignition sources like nail polish.
D: Replacing cotton bedding & clothing with wool is unnecessary for oxygen safety.
While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following is the appropriate intervention?
- A. Have the client hold his breath briefly
- B. Discontinue the fluid instillation
- C. Remind the client that cramping is common at this time
- D. Lower the enema fluid container
Correct Answer: D
Rationale: The correct answer is D: Lower the enema fluid container. This intervention helps slow down the flow of the enema solution, reducing the client's discomfort from cramping. By lowering the container, the rate of fluid instillation decreases, giving the client's body more time to adjust to the enema. This action promotes better tolerance and helps alleviate abdominal cramping.
Other choices are incorrect:
A: Having the client hold his breath briefly does not address the underlying cause of the cramping and may increase discomfort.
B: Discontinuing the fluid instillation abruptly can cause incomplete cleansing and may not address the cramping effectively.
C: Merely reminding the client that cramping is common does not provide immediate relief or help manage the discomfort.
By choosing option D, the nurse can effectively manage the client's cramping during the enema procedure.
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via NG tube. Which of the following is an appropriate nursing action prior to administering the tube feeding? Select all.
- A. Auscultate bowel sounds.
- B. Assist the client to an upright position.
- C. Test the pH of gastric aspirate.
- D. Warm the formula to body temperature.
- E. Discard any residual gastric contents.
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Auscultating bowel sounds is important to assess gastrointestinal motility and ensure the client is ready to receive the feeding.
B: Assisting the client to an upright position helps prevent aspiration during feeding by promoting proper tube placement.
C: Testing the pH of gastric aspirate confirms tube placement in the stomach and prevents potential complications from feeding into the lungs.
Summary:
D: Warming the formula is not necessary before administration and can lead to bacterial growth.
E: Discarding residual gastric contents should be done after assessing the pH, not before.
A nursing instructor is reviewing the wound healing process with a group of nursing students. They should be able to identify which of the following alterations as a wound or injury that heals by secondary intention? Select all.
- A. Stage III pressure ulcer
- B. Sutured surgical incision
- C. Casted bone fracture
- D. Laceration sealed with adhesive
- E. Open burn area
Correct Answer: A, E
Rationale: The correct answers are A and E because wounds healing by secondary intention involve tissue loss and heal from the bottom up with granulation tissue filling in the wound. A Stage III pressure ulcer and an open burn area are examples of wounds that heal by secondary intention due to tissue loss.
Choices B and D are incorrect because sutured surgical incisions and lacerations sealed with adhesive heal by primary intention, where wound edges are approximated and heal with minimal scarring. Choice C, a casted bone fracture, is incorrect as fractures heal through a different process involving the formation of callus and subsequent bone remodeling, not by secondary intention healing.