Nokea
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
- A. Paper mask and gown.
- B. A sputum specimen.
- C. The nurse's stethoscope.
- D. Bed linens.
Correct Answer: A
Rationale: Contaminated mask and gown require biohazard disposal.
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The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?
- A. Morphine 2.0 mg IV every four hours for severe pain.
- B. Morphine 2 mg IV every 4 hr PRN for severe pain.
- C. IV MS 2 mg every 4 hr as needed for severe pain.
- D. IV MS 2.0 mg every 4 hours PRN for severe pain.
Correct Answer: B
Rationale: Full drug name and no trailing zeros ensure clarity.
In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?
- A. Recommend asking the healthcare professional for a patient-controlled analgesia (PCA) pump.
- B. Explain the respiratory problems that can occur with morphine use.
- C. Teach family how to evaluate the effectiveness of analgesics.
- D. Provide client with a schedule of around-the-clock prescribed analgesic use.
Correct Answer: D
Rationale: Scheduled analgesics ensure consistent pain relief.
The healthcare provider prescribes two doses of an antihypertensive medication for a client. Before administering the second dose, the nurse obtains a blood pressure measurement of 80/50 mm Hg. Which action should the nurse take?
- A. Position the client in a lateral lying position.
- B. Document the blood pressure and monitor the client.
- C. Encourage an increase in oral fluid intake.
- D. Hold the medication and notify the healthcare provider.
Correct Answer: D
Rationale: Holding medication prevents worsening hypotension.
The nurse retrieves hydromorphone 4 mg/mL from an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.8
Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.
A bedfast female client awakens during the night, reporting to the nurse that she is 'uncomfortable.' What action should the nurse implement first?
- A. Engage the client in relaxation exercises.
- B. Offer to sit with the client until she relaxes.
- C. Administer a prescribed PRN analgesic.
- D. Assist the client to a different position.
Correct Answer: D
Rationale: Repositioning often relieves discomfort.