Nokea
A client is prescribed morphine sulfate for postoperative pain. Which side effect should the nurse monitor for?
- A. Hypertension
- B. Tachycardia
- C. Respiratory depression
- D. Diarrhea
Correct Answer: C
Rationale: Morphine, an opioid, can cause respiratory depression, a serious side effect requiring close monitoring to ensure client safety.
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Which of the following is not considered one of the 'Ten Rights of Medication Administration'?
- A. The 'right' verification
- B. The 'right' to refuse
- C. The 'right' documentation
- D. The 'right' client education
Correct Answer: A
Rationale: The Ten Rights of Medication Administration include right patient, drug, dose, route, time, documentation, reason, response, refusal, and education. 'Right verification' is not a standard right.
The nurse administering a dose of scopolamine to a preoperative client should monitor the client for which common side effect of the medication?
- A. Dry mouth
- B. Diaphoresis
- C. Excessive urination
- D. Pupillary constriction
Correct Answer: A
Rationale: Scopolamine is an anticholinergic medication that causes the frequent side effects of dry mouth, urinary retention, decreased sweating, and dilation of the pupils. Each of the incorrect options is the opposite of a side effect of this medication.
The nurse is performing routine tracheostomy care. Which of the following steps would be appropriate for the nurse to include in the performance of the procedure?
- A. Remove the inner cannula every 2 hours for cleaning.
- B. Secure the tracheostomy ties with a square knot.
- C. Use cut gauze under the neck plate to protect the skin.
- D. Suction the inner cannula on completion of the procedure.
Correct Answer: B
Rationale: Securing tracheostomy ties with a square knot ensures stability and safety. Frequent cannula removal is unnecessary, cut gauze may fray, and suctioning is done as needed, not routinely.
A client has been defibrillated at 360 joules (monophasic) and the attempts to convert the ventricular fibrillation (VF) were unsuccessful. Based on an evaluation of the situation, the nurse determines that which action is best?
- A. Terminating the resuscitation effort
- B. Preparing for the administration of sodium bicarbonate intravenously
- C. Performing cardiopulmonary resuscitation (CPR) for 5 cycles or about 2 minutes
- D. Performing CPR for 5 minutes, then defibrillating 3 more times at 400 joules
Correct Answer: C
Rationale: Defibrillation is an asynchronous countershock used to terminate pulseless ventricular tachycardia (VT) or ventricular fibrillation (VF). The defibrillator is charged to 120 to 200 joules (biphasic) or 300 joules (monophasic) for 1 countershock from the defibrillator, and then CPR is immediately resumed and continued for 5 cycles or about 2 minutes. The rhythm is reassessed after 2 minutes and if VF or pulseless VT continues, the defibrillator is charged to give a second shock at the same energy level previously used. CPR is resumed after the shock if needed and the life support protocol is continued. There is no information in the question to indicate that life support should be terminated. Sodium bicarbonate may be prescribed but is not the best action. Giving CPR for 5 minutes may not help oxygenation to the brain and myocardium and is not the best action.
A 15-month-old child is admitted to the pediatric unit with the diagnosis of pneumonia and is placed in a mass test. Which following toys would be appropriate for this child?
- A. A pull toy.
- B. Storybooks.
- C. Crayons and paper.
- D. Plastic blocks.
Correct Answer: D
Rationale: Plastic blocks are safe and age-appropriate for a 15-month-old, promoting fine motor skills without posing a choking hazard or requiring mobility restricted by a mist tent.