Nokea
A client is given morphine 6 mg IV push for postoperative pain.
- A. What is the most appropriate nursing action for a client with pulse 68, respirations 8, BP 100/68, and sleeping quietly after receiving morphine 6 mg IV?
- B. Allow the client to sleep undisturbed.
- C. Administer oxygen via facemask or nasal prongs.
- D. Administer naloxone (Narcan).
- E. Place epinephrine 1:1,000 at the bedside.
Correct Answer: C
Rationale: A respiratory rate of 8 indicates respiratory depression, a serious side effect of morphine. Administering naloxone (Narcan) is the most appropriate action to reverse this effect. Allowing the client to sleep risks further respiratory compromise, oxygen may be used after naloxone, and epinephrine is not indicated.
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A client presents with confusion, mood lability, impaired communication, and lethargy.
The nurse should question which of the following orders?
- A. Dexamethasone suppression Test .
- B. Thyroid studies.
- C. Drug toxicology screen.
- D. Trendelenburg Test .
Correct Answer: D
Rationale: Strategy: Think about each Test . (1) may be ordered to determine the presence of major depression (2) may be ordered to check for an endocrine cause for the symptoms before the diagnosis of dementia is made (3) may be ordered to see if the client's symptoms are caused by excessive use of medications or alcohol (4) correct-Test is used with a client who may have varicose veins, no relationship to the symptoms described in this situation
The nurse is caring for a client with a history of chronic pain.
- A. Which intervention is most effective for managing chronic pain?
- B. Administer analgesics as needed only.
- C. Encourage participation in a pain management program.
- D. Restrict physical activity to reduce pain.
- E. Apply ice packs to the painful area.
Correct Answer: B
Rationale: A pain management program (e.g., cognitive-behavioral therapy, physical therapy) addresses chronic pain holistically, improving function and coping. PRN analgesics are less effective long-term, activity is encouraged, and ice is condition-specific.
An adult who has just been diagnosed with pulmonary tuberculosis asks the nurse how long he will have to be in isolation. What should be included in the nurse's reply?
- A. Isolation is for the duration of the treatment, which is at least 26 weeks.
- B. Isolation is necessary as long as the client has a cough.
- C. When the client has three negative sputum specimens, isolation is discontinued.
- D. When the evening fevers and night sweats subside, isolation is discontinued.
Correct Answer: C
Rationale: Isolation for pulmonary TB ends when three consecutive sputum samples are negative, indicating non-infectiousness, typically before the full 6-month treatment.
A client who is receiving a blood transfusion experiences a hemolytic reaction. The nurse would anticipate which of the following assessment findings?
- A. Hypotension, backache, low back pain, fever.
- B. Wet breath sounds, severe shortness of breath.
- C. Chills and fever occurring about an hour after the infusion started.
- D. Urticaria, itching, respiratory distress.
Correct Answer: A
Rationale: signs and symptoms of a hemolytic reaction include chills, headache, backache, dyspnea, cyanosis, chest pains, tachycardia, and hypotension
The nurse is teaching parents about the appropriate diet for a 4 month-old infant with gastroenteritis and mild dehydration. In addition to oral rehydration fluids, the diet should include
- A. formula or breast milk
- B. broth and tea
- C. rice cereal and apple juice
- D. gelatin and ginger ale
Correct Answer: A
Rationale: The usual diet for a young infant should be followed.