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A nurse is caring for a client who has a prescription for a narcotic medication. After administration, what should the nurse do with the unused portion?
- A. Document the amount wasted
- B. Store it for later use
- C. Discard it with another nurse as a witness
- D. Return it to the pharmacy
Correct Answer: C
Rationale: After administering a narcotic medication, any unused portion should be discarded with another nurse as a witness. This procedure ensures proper disposal of controlled substances and prevents misuse or diversion. Storing it for later use (Choice B) is not appropriate due to safety concerns and legal regulations. Returning it to the pharmacy (Choice D) is also not recommended as the medication is already out of the pharmacy's control. Documenting the amount wasted (Choice A) is important for accurate record-keeping but does not address the immediate need for safe disposal of the unused narcotic medication.
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A nurse is caring for a client who reports a decrease in the effectiveness of their pain medication. What factor should the nurse identify as contributing to this decrease?
- A. History of frequent alcohol use
- B. Decreased physical activity
- C. Bowel inflammation
- D. History of opioid use
Correct Answer: C
Rationale: The correct answer is C: Bowel inflammation. Bowel inflammation can interfere with the absorption of medications, including pain medication, leading to decreased effectiveness. Choices A, B, and D are incorrect because although they can impact pain management in various ways, they are not directly related to the decreased effectiveness of pain medication due to absorption issues.
A nurse is assessing a client who reports pain and tenderness at the site of an indwelling urinary catheter. What is the nurse's first action?
- A. Irrigate the catheter with normal saline
- B. Notify the provider
- C. Assess for signs of infection
- D. Administer prescribed antibiotics
Correct Answer: B
Rationale: The correct first action for the nurse to take when a client reports pain and tenderness at the site of an indwelling urinary catheter is to notify the provider. Pain and tenderness at the catheter site may indicate infection, and the healthcare provider needs to be informed for further assessment and appropriate interventions. Irrigating the catheter with normal saline (Choice A) should not be the initial action without consulting the provider first. While assessing for signs of infection (Choice C) is important, notifying the provider takes precedence. Administering prescribed antibiotics (Choice D) should only be done based on the provider's orders after assessment and confirmation of infection.
A nurse is caring for a client who is postoperative following abdominal surgery. What behavior should the nurse identify as increasing the client's risk for constipation?
- A. Increased physical activity
- B. Frequent urge suppression
- C. Adequate sleep
- D. Increased fluid intake
Correct Answer: B
Rationale: Frequent urge suppression can lead to constipation, especially postoperatively. Suppressing the urge to defecate can disrupt the normal bowel movement pattern and lead to constipation. Choices A, C, and D are behaviors that generally help prevent constipation rather than increase the risk. Increased physical activity, adequate sleep, and increased fluid intake promote bowel regularity and reduce the risk of constipation.
A healthcare provider is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare provider use?
- A. Verbal self-report
- B. Pain scale
- C. Behavioral indicators
- D. Observing facial expressions
Correct Answer: C
Rationale: In clients with dementia and difficulty communicating, using behavioral indicators such as agitation and restlessness is more reliable for assessing pain than relying on verbal self-report, pain scales, or observing facial expressions. Verbal self-report may not be possible due to communication challenges, pain scales may be difficult for the client to comprehend, and observing facial expressions alone may not provide a comprehensive assessment of pain in individuals with dementia.
A nurse is assessing the IV infusion site of a client who reports pain at the site. The site is red, and there is warmth along the course of the vein. What should the nurse do?
- A. Increase the IV flow rate
- B. Discontinue the infusion
- C. Elevate the limb
- D. Apply a cold compress
Correct Answer: B
Rationale: The correct answer is to discontinue the infusion (Choice B) as the signs described suggest phlebitis, an inflammation of the vein. Increasing the IV flow rate (Choice A) can exacerbate the condition by increasing the irritation. Elevating the limb (Choice C) and applying a cold compress (Choice D) are not the appropriate interventions for phlebitis. Elevation and cold therapy are more suitable for conditions like swelling or inflammation, but in this case, discontinuing the infusion is the priority to prevent further complications.