Nokea
A client requests a narcotic analgesic shortly after the oncoming nurse receives change-of-shift report. The nurse who is leaving reported that the client had received morphine 10 mg (IM) within the past hour. The nurse should ask the outgoing RN to do which of the following actions?
- A. Validate with the outgoing RN that morphine 10 mg (IM) had been administered.
- B. Assess the client for manifestations of pain.
- C. Check the medication documentation as to when morphine 10 mg (IM) was dispensed and to whom.
- D. Check to ascertain if any discrepancy had been documented with accompanying reason/s.
Correct Answer: A
Rationale: Validating with the outgoing RN confirms the morphine administration, ensuring safe timing of the next dose and preventing overdose.
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An older adult takes two 81 mg aspirin tablets daily to prevent a heart attack. The client reports having a constant 'ringing' in both ears. How should the nurse respond to the client's comment?
- A. Tell the client that 'ringing' in the ears is associated with the aging process.
- B. Refer the client to have a hearing test.
- C. Schedule the client for audiometric testing.
- D. Explain to the client that the 'ringing' may be related to the aspirin.
Correct Answer: D
Rationale: Aspirin, even at low doses, can cause tinnitus (ringing in the ears) as a side effect. The nurse should explain this potential link and advise consulting the physician.
The nurse is caring for a client with Crohn's disease who reports frequent nighttime diarrhea. Which intervention should the nurse prioritize?
- A. Administer an antidiarrheal as ordered.
- B. Encourage a high-fiber diet.
- C. Schedule meals earlier in the day.
- D. Provide a bedside commode.
Correct Answer: D
Rationale: Providing a bedside commode is the priority to ensure safety and comfort for a client with frequent nighttime diarrhea due to Crohn's disease. Antidiarrheals may be used but require careful monitoring, a high-fiber diet may worsen symptoms, and meal timing is less impactful. CN: Physiological adaptation; CL: Synthesize
A client is newly diagnosed with cancer and is beginning a treatment plan. Which of the following nursing interventions will be most effective in helping the client cope?
- A. Assume decision making for the client.
- B. Encourage the client's compliance with all treatment regimens.
- C. Inform the client of all possible adverse treatment effects.
- D. Identify available resources.
Correct Answer: D
Rationale: Identifying available resources (e.g., support groups, counseling) empowers the client to cope with the emotional and practical challenges of a new cancer diagnosis.
A female client who has a urinary diversion tells the nurse, 'This urinary pouch is embarrassing. Everyone will know that I'm not normal. I don't see how I can go out in public anymore.' The most appropriate nursing diagnosis for this client is:
- A. Anxiety related to the presence of a urinary diversion.
- B. Deficient knowledge about how to care for the urinary diversion.
- C. Low self-esteem related to feelings of worthlessness.
- D. Unstuffed body image related to creation of a urinary diversion.
Correct Answer: D
Rationale: The client's statement reflects distress about the urinary diversion's impact on her appearance and social life, indicating a disturbed body image.
The nurse is preparing to administer a prescribed medication to a client. The nurse should take which initial action?
- A. Verify the client's full name and date of birth
- B. Ask about any medication allergies
- C. Review the client's vital signs
- D. Review medications and potential interactions
Correct Answer: A
Rationale: Verifying client identity using two identifiers is the initial step to ensure safe medication administration.