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A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?
- A. Respiratory rate of 20/min
- B. Oxygen saturation of 93%
- C. Pain level of 2 on a scale of 0 to 10
- D. Blood pressure of 110/70 mm Hg
Correct Answer: D
Rationale: The correct answer is D because a blood pressure drop or other signs of morphine overdose should be reported, especially when using a PCA pump. Choices A, B, and C are within normal limits and do not indicate an immediate concern related to morphine administration.
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A nurse is planning care for a client who has chronic kidney disease. The nurse should identify which of the following laboratory values as an indication for hemodialysis?
- A. Glomerular filtration rate of 14 mL/minute
- B. BUN 16 mg/dL
- C. Serum magnesium 1.8 mg/dL
- D. Serum phosphorus 4.0 mg/dL
Correct Answer: A
Rationale: A glomerular filtration rate of 14 mL/minute indicates severe kidney dysfunction, necessitating hemodialysis. The other options, BUN of 16 mg/dL, serum magnesium of 1.8 mg/dL, and serum phosphorus of 4.0 mg/dL, are within normal ranges and do not serve as indications for hemodialysis.
A nurse is planning care for a client who has a new diagnosis of heart failure. Which of the following interventions should the nurse include in the plan of care?
- A. Limit the client's fluid intake to 1,500 mL per day.
- B. Encourage the client to walk every 2 hours.
- C. Monitor the client's weight daily.
- D. Administer oxygen via nasal cannula at 2 L/min.
Correct Answer: C
Rationale: The correct intervention the nurse should include in the plan of care for a client with heart failure is to monitor the client's weight daily. Daily weight monitoring is essential to assess fluid balance and detect any signs of worsening heart failure. Limiting fluid intake to 1,500 mL per day (Choice A) may be appropriate in some cases, but it is not the initial priority for this client. Encouraging the client to walk every 2 hours (Choice B) is generally beneficial for mobility but may not be directly related to managing heart failure. Administering oxygen via nasal cannula at 2 L/min (Choice D) is a supportive measure for hypoxia but does not directly address heart failure management.
How should a healthcare professional assess for infection in a patient post-surgery?
- A. Check the surgical site
- B. Check for fever
- C. Check for abnormal breath sounds
- D. Check the patient's skin color
Correct Answer: A
Rationale: When assessing for infection in a patient post-surgery, checking the surgical site is crucial. Changes in the appearance of the surgical site, such as redness, swelling, warmth, or drainage, can indicate an infection. While checking for fever (Choice B) is also important as it can be a sign of infection, it is a more general symptom and may not always be present. Checking for abnormal breath sounds (Choice C) and skin color (Choice D) are not typically direct indicators of infection in a post-surgery patient.
What is the priority nursing action for a patient with confusion post-surgery?
- A. Administer oxygen
- B. Reposition the patient
- C. Check oxygen saturation
- D. Perform a neurological exam
Correct Answer: A
Rationale: The correct answer is to administer oxygen. Post-surgery, confusion in a patient could be due to hypoxia, a condition where the body is deprived of an adequate oxygen supply. Administering oxygen helps address hypoxia promptly, improving oxygen levels in the body and potentially resolving the confusion. Repositioning the patient, checking oxygen saturation, and performing a neurological exam may be important interventions but addressing hypoxia with oxygen administration takes precedence as the priority action.
How should a healthcare provider respond to a patient with a history of hypertension who is non-compliant with medication?
- A. Encourage compliance through education
- B. Contact the healthcare provider
- C. Document the refusal
- D. Explore alternative treatment options
Correct Answer: A
Rationale: Encouraging compliance through education is crucial in helping patients understand the importance of consistent medication use. By providing education, the patient can make informed decisions about their health and better manage their condition. Contacting the healthcare provider (choice B) may be necessary in some cases, but the initial approach should focus on patient education. Documenting the refusal (choice C) is important for legal and medical records but does not address the root cause of non-compliance. Exploring alternative treatment options (choice D) should come after efforts to educate and encourage compliance with the current medication regimen.