Nokea
A client with advanced ovarian cancer takes 150 mg of long-acting morphine orally every 12 hours for abdominal pain. When the client develops a small bowel obstruction, the physician discontinues the oral morphine and begins morphine 6 mg/hour I.V. After calculating the equianalgesic conversion from oral to intravenous morphine, the nurse should:
- A. Continue the oral morphine for one more dose after the I.V. morphine is started.
- B. Contact the physician to suggest a higher equianalgesic dose of I.V. morphine.
- C. Administer the morphine I.V. as ordered.
- D. Clarify the order to recommend the initial morphine dose of 4 mg/hour.
Correct Answer: B
Rationale: The equianalgesic conversion from 150 mg oral morphine every 12 hours (300 mg/day oral) to I.V. morphine (1:3 ratio) is approximately 100 mg/day I.V., or 4.2 mg/hour. The ordered 6 mg/hour is too high, and the nurse should contact the physician to adjust the dose.
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When teaching about prevention of infection to a client with a long-term venous catheter, the nurse can document that the client has understood discharge instructions when the client states which of the following?
- A. I will not remove the dressing until I return to the clinic next week.
- B. My husband or I will do the dressing changes three times per week, exactly the way you showed us.
- C. I will monitor my temperature once each weekday.
- D. I know it is very important to wash my hands after irrigating the catheter.
Correct Answer: B
Rationale: Regular dressing changes (three times per week) performed correctly indicate understanding of infection prevention for a long-term venous catheter.
A client who had an exploratory laparotomy 3 days ago has a white blood cell (WBC) differential with a shift to the left. The nurse instructs unlicensed personnel to report which clinical manifestation?
- A. Swelling around the incision.
- B. Redness around the incision.
- C. Elevated temperature.
- D. Purulent wound drainage.
Correct Answer: C
Rationale: A left shift in the WBC differential indicates an increase in immature neutrophils, often due to infection. An elevated temperature is a key sign of infection and should be reported promptly. Swelling, redness, and purulent drainage are also concerning but may develop later.
The nurse is caring for a client with Meniere's Disease. Which of the following assessment findings would be expected? Select all that apply.
- A. Presbyopia
- B. Tinnitus
- C. Vertigo
- D. Dyskinesia
- E. Hearing loss
Correct Answer: B,C,E
Rationale: Meniere's disease is characterized by tinnitus (ringing in the ears), vertigo (spinning sensation), and hearing loss due to inner ear dysfunction. Presbyopia (age-related vision loss) and dyskinesia (abnormal movements) are not associated with Meniere's disease.
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?
- A. 10 seconds.
- B. 15 seconds.
- C. 25 seconds.
- D. 30 seconds.
Correct Answer: B
Rationale: Suctioning for no more than 15 seconds prevents hypoxia and trauma to the airway. Longer durations risk oxygen deprivation.
A client with a spinal cord injury who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears, one day he asks the nurse, 'Why can't I stop talking about these things? I know those days are gone forever.' Which of the following responses by the nurse conveys the best understanding of the client's behavior?
- A. Be patient. It takes time to adjust to such a massive loss.'
- B. I will be sure to tell the team that reviewing the past is a form of denial. We have to help you focus on today.'
- C. Reviewing your losses is a way to help you work through your grief and loss.'
- D. It's a simple escape mechanism to go back and live again in happier times.'
Correct Answer: C
Rationale: Reflecting on past activities is part of grieving, helping the client process the loss of function.