Nokea
A client has received 10 mg of morphine sulfate subcutaneously. When does the nurse anticipate the maximal period of respiratory depression will occur?
- A. 7 minutes
- B. 30 minutes
- C. 60 minutes
- D. 90 minutes
Correct Answer: A
Rationale: Morphine sulfate administered subcutaneously reaches peak effect, including respiratory depression, within 5-10 minutes. Thus, 7 minutes (A) is the most accurate time frame.
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The nurse is seeing a client and her 11-month-old baby in the clinic for a wellness checkup. Which comment by the mother would prompt the nurse to notify the health care provider?
- A. She loves to play peekaboo.
- B. She loves to look at herself in the mirror.
- C. She does not like to be around strangers.
- D. She does not try to crawl when I put her down.
Correct Answer: D
Rationale: Lack of crawling at 11 months may indicate developmental delay, requiring provider evaluation. Other behaviors are age-appropriate.
The nurse is caring for a client with a wound that presents with full-thickness tissue loss and eschar covering the wound bed. The nurse would record this wound as which stage?
- A. Stage I
- B. Stage II
- C. Stage III
- D. Stage IV
- E. unstageable
Correct Answer: E
Rationale: Eschar covering the wound bed makes it unstageable, as the depth cannot be assessed until debridement.
A homeless client has been admitted to the hospital for observation, and he does not speak any English. The nurse does not know any of the client's medical history, but he is grimacing and looks to be in pain. The nurse should
- A. use nonverbal communication such as pointing and gestures.
- B. call for the hospital interpreter services.
- C. give the client pen and paper and encourage him to draw.
- D. wait to see if any friends or family visit the client who may be able to help.
Correct Answer: B
Rationale: An interpreter ensures accurate communication for assessing pain and history, respecting patient needs and safety.
Which of the following pediatric clients is at greatest risk for latex allergy?
- A. The child with a myelomeningocele
- B. The child with epispadias
- C. The child with coxa plana
- D. The child with rheumatic fever
Correct Answer: A
Rationale: Children with myelomeningocele are at higher risk for latex allergy due to repeated exposure to latex products during medical procedures.
The nurse is preparing to administer insulin to a client with type 1 diabetes mellitus. The client is to receive 10 units of regular insulin and 20 units of NPH insulin. Which of the following actions by the nurse is correct?
- A. Draw up the NPH insulin first, then the regular insulin in the same syringe.
- B. Administer the regular insulin in one syringe and the NPH in another.
- C. Mix the regular insulin with the NPH insulin in a vial before drawing it up.
- D. Administer the regular insulin 30 minutes after the NPH insulin.
Correct Answer: A
Rationale: regular insulin is drawn up first, followed by NPH, to prevent contamination of the regular insulin with NPH