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A nurse is caring for a client who had total hip arthroplasty 1 day ago and is receiving morphine sulfate by PCA pump for pain control. The client reports nausea and vomiting. Which of the following actions should the nurse take?
- A. Insert a nasogastric tube.
- B. Administer an antiemetic.
- C. Auscultate bowel sounds.
- D. Encourage the client to ambulate.
Correct Answer: B
Rationale: The correct answer is B: Administer an antiemetic. Nausea and vomiting are common side effects of morphine sulfate. Administering an antiemetic will help relieve these symptoms without interfering with the pain control provided by the PCA pump. Inserting a nasogastric tube (choice A) is not indicated as there is no indication of bowel obstruction. Auscultating bowel sounds (choice C) is not the priority in this situation. Encouraging the client to ambulate (choice D) may help with bowel motility but addressing the nausea and vomiting is the immediate concern.
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A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?
- A. Exophthalmos
- B. Photophobia
- C. Lethargy
- D. Weight loss
Correct Answer: C
Rationale: Rationale: Hypothyroidism is characterized by decreased thyroid hormone levels, leading to symptoms such as lethargy due to slowed metabolism. Exophthalmos (bulging eyes) is associated with hyperthyroidism. Photophobia (sensitivity to light) is not a common symptom of hypothyroidism. Weight loss is more indicative of hyperthyroidism due to increased metabolism. Therefore, the correct answer is C: Lethargy, as it aligns with the expected findings in hypothyroidism.
A nurse is providing discharge teaching to a client who has a new diagnosis of heart failure. Which of the following instructions should the nurse include in the teaching?
- A. Take naproxen for generalized discomfort
- B. Notify the provider of a weight gain of 0.5 kg (1 lb) in a week
- C. Take diuretics early in the morning and before bedtime
- D. Exercise at least three times per week
Correct Answer: B
Rationale: The correct answer is B: Notify the provider of a weight gain of 0.5 kg (1 lb) in a week. This is crucial in heart failure management as sudden weight gain can indicate fluid retention, worsening heart failure, and the need for medication adjustment. Option A is incorrect as naproxen can worsen heart failure symptoms. Option C is incorrect as diuretics should be taken in the morning to prevent nighttime urination. Option D is incorrect as the frequency and intensity of exercise should be tailored based on the individual's condition.
A nurse is caring for a client who suspects recent exposure to inhalation anthrax. Which of the following findings indicate possible exposure?
- A. Vesicles on the skin
- B. Respiratory failure
- C. Flu-like symptoms
- D. Coughing of blood
Correct Answer: B
Rationale: The correct answer is B: Respiratory failure. Inhalation anthrax primarily affects the respiratory system, causing symptoms such as difficulty breathing, cough, and chest discomfort. Respiratory failure can occur in severe cases. Vesicles on the skin (A) are not typically associated with inhalation anthrax. Flu-like symptoms (C) are nonspecific and can be seen with various infections. Coughing of blood (D) is not a common symptom of inhalation anthrax. Therefore, the most indicative finding of possible exposure to inhalation anthrax is respiratory failure.
A nurse is caring for a client whose family member requests to view the client’s medical record. Which of the following responses should the nurse make?
- A. The ethics committee will need to approve this request for you.
- B. I will ask the nursing supervisor to obtain the medical records for you.
- C. The healthcare provider will share this information with you.
- D. The client must provide permission to share the records with you.
Correct Answer: D
Rationale: The correct response is D: The client must provide permission to share the records with you. This is the correct answer because under HIPAA regulations, a client's medical records are confidential and can only be shared with the client's explicit permission. The nurse cannot disclose the records to a family member without the client's consent. Option A is incorrect because the ethics committee does not handle individual requests for medical records. Option B is incorrect as the nursing supervisor cannot release medical records without proper authorization. Option C is incorrect as the healthcare provider cannot share the information without the client's consent.
A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride IV to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number)
Correct Answer: 100
Rationale: The correct answer is 100 gtt/min. To calculate the IV flow rate in gtt/min for microtubing, you can use the formula: gtt/min = (mL/hr x tubing factor) / 60. In this case, the mL/hr is 100, and for microtubing, the tubing factor is usually 60. So, (100 x 60) / 60 = 100 gtt/min. This ensures the dextrose 5% in 0.45% sodium chloride solution is infused at the correct rate. Other choices would be incorrect because they do not follow the correct calculation for microtubing flow rates.