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A nurse is caring for a client who had abdominal surgery. The client is grimacing and has a respiratory rate of 24/min. Which of the following actions should the nurse take first?
- A. Offer the client a cold compress.
- B. Play music in the client's room as a distraction.
- C. Check the client's current level of pain.
- D. Assist the client to reposition in bed.
Correct Answer: C
Rationale: The correct answer is C: Check the client's current level of pain. The nurse should assess the client's pain first to determine the cause of grimacing and tachypnea. Pain after abdominal surgery can indicate complications like infection or inadequate pain management. Addressing pain is a priority to ensure the client's comfort and prevent further complications. Options A, B, and D do not address the underlying issue of pain and are therefore not the most appropriate actions. Offering a cold compress or playing music may provide temporary relief but do not address the root cause. Repositioning may help with comfort but should come after assessing and addressing the pain.
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A nurse is collecting data from a client who is experiencing oxycodone toxicity. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Sedation
- C. Dilated pupils
- D. Tachypnea
Correct Answer: B
Rationale: The correct answer is B: Sedation. Oxycodone is an opioid that depresses the central nervous system, leading to symptoms such as sedation or drowsiness. This is because opioids like oxycodone bind to opioid receptors in the brain, causing a calming effect. Tachycardia (A) and dilated pupils (C) are more commonly associated with stimulant toxicity rather than opioid toxicity. Tachypnea (D) is not a typical finding in opioid toxicity as opioids tend to depress the respiratory system, causing respiratory depression instead.
A nurse is reinforcing teaching with a client who has a new prescription for prednisone to treat rheumatoid arthritis. Which of the following statements should indicate to the nurse that the client understands the teaching?
- A. I should watch for weight loss.
- B. I should increase the sodium in my diet.
- C. I will take this medication on an empty stomach.
- D. I will report a sore throat to my provider.
Correct Answer: D
Rationale: The correct answer is D: "I will report a sore throat to my provider." This is the correct answer because prednisone can suppress the immune system, increasing the risk of infections like thrush or sore throat. Reporting these symptoms promptly is crucial to prevent complications.
Choice A is incorrect because prednisone can actually cause weight gain. Choice B is incorrect because prednisone can lead to fluid retention, so increasing sodium intake is not recommended. Choice C is incorrect because prednisone should be taken with food to reduce stomach upset.
A nurse is caring for a client who has a prescription for morphine 4 mg IM stat. The medication is dispensed in a 5 mg/mL prefilled syringe. Which of the following actions should the nurse take?
- A. Dispose of the excess medication in the sharps container.
- B. Give the full contents of the prefilled syringe.
- C. Discard the excess medication with a second nurse as a witness.
- D. Inject the prescribed dose and save the rest for a later use.
Correct Answer: C
Rationale: The correct answer is C: Discard the excess medication with a second nurse as a witness. The nurse should discard the excess medication in the presence of another nurse to ensure proper disposal and avoid any medication errors or potential harm to the patient. This action aligns with medication safety practices and helps prevent medication errors.
Choice A: Disposing of the excess medication in the sharps container is incorrect because it does not involve a witness for proper disposal and may not follow facility protocols.
Choice B: Giving the full contents of the prefilled syringe would result in administering more medication than prescribed, risking harm to the patient.
Choice D: Injecting the prescribed dose and saving the rest for later use is incorrect as it goes against safe medication practices and may lead to errors in dosing.
In summary, choice C is the correct action to ensure safe and appropriate disposal of excess medication, while the other choices may lead to potential errors and harm to the patient.
A nurse is reinforcing discharge teaching with a client who has a prescription for rifampin for the treatment of tuberculosis (TB). Which of the following instructions should the nurse include in the teaching?
- A. Take the medication on an empty stomach.
- B. Discontinue the medication if your saliva turns orange.
- C. Return for another TB skin test in 3 months.
- D. You will need to take this medication for 1 week.
Correct Answer: A
Rationale: The correct answer is A: Take the medication on an empty stomach. Rifampin is best absorbed when taken on an empty stomach, usually 1 hour before or 2 hours after meals. This maximizes its effectiveness in treating TB. Choice B is incorrect because discoloration of body fluids (including saliva) is a known side effect of rifampin and does not indicate the need to discontinue the medication. Choice C is incorrect because the client should not return for another TB skin test in 3 months unless specifically instructed by the healthcare provider. Choice D is incorrect because treatment for TB usually lasts for several months, not just 1 week.
A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The nurse should identify which of the following findings as an indication of a febrile nonhemolytic reaction?
- A. Dyspnea
- B. Urticaria
- C. Chills
- D. Vomiting
Correct Answer: C
Rationale: The correct answer is C: Chills. A febrile nonhemolytic reaction during a blood transfusion is characterized by the sudden onset of chills and fever, usually within the first 15 minutes to 2 hours of the transfusion. This reaction is caused by the recipient's antibodies reacting to donor leukocytes. Dyspnea (A), urticaria (B), and vomiting (D) are more indicative of other transfusion reactions such as an allergic reaction, hemolytic reaction, or bacterial contamination, respectively.