Nokea
A 62-year-old female is taking long-acting morphine 120 mg every 12 hours for pain from metastatic breast cancer. She can have 20 mg of immediate-release morphine every 3 to 4 hours as needed for breakthrough pain. The physician should be notified if the client uses more than how many breakthrough doses of morphine in 24 hours?
- A. Seven.
- B. Four.
- C. Two.
- D. One.
Correct Answer: B
Rationale: More than four breakthrough doses (80 mg additional morphine) in 24 hours indicates inadequate baseline pain control, requiring physician notification to adjust the long-acting morphine dose.
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A client with a history of heart failure has bilateral +4 edema of her right ankle that extends up to midcalf. She is sitting out of bed and has her legs in a dependent position. Which of the following goals is the priority?
- A. Decrease venous congestion
- B. Maintain normal respirations
- C. Maintain body temperature
- D. Prevent injury to lower extremities
Correct Answer: A
Rationale: Bilateral edema in heart failure results from increased venous pressure and congestion due to impaired cardiac output. The priority goal is to decrease venous congestion (e.g., by elevating legs or using compression) to reduce edema and improve circulation. Respirations, temperature, and injury prevention are secondary in this context.
The nurse is to administer midazolam (Versed) 2.5 mg. The medication is available in a 5 mg/mL vial. The nurse should administer ___ mL.
Correct Answer: 0.5
Rationale: To administer 2.5 mg from a 5 mg/mL vial, calculate: 2.5 mg ÷ 5 mg/mL = 0.5 mL. This is a calculation question, not multiple-choice, but included as per instructions.
When preparing a teaching plan for an adult client about general anesthesia induction, which explanation would be most appropriate?
- A. œYour premedication will put you to sleep.'
- B. œYou will breathe in an inhalant anesthetic mixed with oxygen through a facial mask and receive intravenous medication to make you sleepy.'
- C. œYou will receive intravenous medication to make you sleepy.'
- D. œYou will breathe in medication through a facial mask to make you sleepy.'
Correct Answer: C
Rationale: For adults, explaining that intravenous medication induces sleep is accurate and simple, avoiding overwhelming details while addressing the primary method of general anesthesia induction.
On the fourth day after surgery, a client has a postoperative wound infection. Which of the following should the nurse assess? Select all that apply.
- A. Total white blood count (WBC) 10,000/mm³.
- B. Redness and swelling beyond the incision line.
- C. Temperature of 102°F (38.9°C).
- D. Client reports of pain at the incision site.
- E. Warmth at the incision site.
Correct Answer: B,C,D,E
Rationale: Signs of wound infection include redness/swelling (B), fever (C), pain (D), and warmth (E). A WBC of 10,000/mm³ (A) is normal and not indicative of infection.
The nurse should be especially alert for signs and symptoms of digoxin toxicity if serum levels indicate that the client has a:
- A. Low sodium level.
- B. High glucose level.
- C. High calcium level.
- D. Low potassium level.
Correct Answer: D
Rationale: Low potassium (hypokalemia) increases the risk of digoxin toxicity by enhancing digoxin's binding to cardiac cells, leading to arrhythmias.