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A nurse is caring for a client who is receiving morphine through a PCA device. Which of the following actions should the nurse take?
- A. Teach the client how to self-medicate using the PCA device.
- B. Encourage family members to press the PCA button for the client.
- C. Monitor the client's respiratory status every 4 hr.
- D. Administer an oral opioid for breakthrough pain.
Correct Answer: A
Rationale: The correct answer is A. Teaching the client how to self-medicate using the PCA device is essential to empower the client in managing their pain effectively. This promotes autonomy and ensures the client receives the appropriate dose at the right time, enhancing pain control. Choice B is incorrect as family members should not press the PCA button for the client to maintain safety and prevent medication errors. Choice C is incorrect as respiratory status should be monitored more frequently, ideally every 1-2 hours, when a client is receiving opioids due to the risk of respiratory depression. Choice D is incorrect as administering an oral opioid for breakthrough pain may lead to overdose or adverse effects when already receiving morphine through PCA.
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A nurse in the PACU is caring for a client. Which of the following assessments is the nurse's priority?
- A. Level of consciousness
- B. Surgical site
- C. Pain level
- D. Respiratory status
Correct Answer: D
Rationale: The correct answer is D: Respiratory status. In the PACU, ensuring adequate oxygenation and ventilation is crucial for the client's immediate postoperative recovery. Monitoring respiratory status helps prevent complications like hypoxia or respiratory distress. Assessing the airway, breathing rate, depth, and oxygen saturation takes precedence over other assessments. Level of consciousness (A) is important but can be affected by respiratory issues. Surgical site (B) assessment is important but not an immediate priority. Pain level (C) is important but can be managed once respiratory status is stable. Summary: Respiratory status is the priority as it directly impacts the client's immediate well-being and recovery.
A nurse is caring for a client who is experiencing a seizure. Which of the following actions should the nurse take first?
- A. Lower the client to the floor.
- B. Obtain the client's vital signs.
- C. Loosen the client's restrictive clothing.
- D. Clear items from the client's surrounding are
Correct Answer: D
Rationale: The correct action to take first when caring for a client experiencing a seizure is to clear items from the client's surrounding area (Choice D). This is important to prevent injury to the client during the seizure. By removing objects that could cause harm, such as sharp or hard items, the nurse ensures a safe environment for the client. Lowering the client to the floor (Choice A) is important but should be done after clearing the surroundings to prevent injury. Obtaining vital signs (Choice B) and loosening restrictive clothing (Choice C) can be done after ensuring the safety of the environment. Thus, the priority is to clear items from the client's surrounding area to prevent harm during the seizure.
Which actions should the nurse take? (Select all that apply)
- A. Anticipate client to be prepped for cardiac catheterization
- B. Assist with a continuous heparin infusion
- C. Encourage the client to ambulate
- D. Anticipate an increased dosage of metoprolol
- E. Obtain a prescription for client to be NPO
- F. Request a prescription for an antibiotic
Correct Answer: A, B, D,E
Rationale: The nurse should anticipate cardiac catheterization prep (A) to ensure client readiness. Continuous heparin infusion (B) prevents clot formation during the procedure. Increased metoprolol dosage (D) may be needed for cardiac stability. NPO status (E) is crucial to prevent complications during the procedure. Ambulation (C) may be contraindicated due to the invasive nature of the procedure. Antibiotics (F) are not routinely needed for cardiac catheterization prep.
A nurse is providing instructions about foot care for a client who has peripheral arterial disease. The nurse should identify that which of the following statements by the client indicates an understanding of the teaching?
- A. I apply a lubricating lotion to the cracked areas on the soles of my feet every morning.'
- B. I rest in my recliner with my feet elevated for about an hour every afternoon.'
- C. I use my heating pad on a low setting to keep my feet warm.'
- D. I soak my feet in hot water before trimming my toenails.'
Correct Answer: A
Rationale: The correct answer is A because applying a lubricating lotion to the cracked areas on the soles of the feet helps prevent further skin breakdown and infection, which is crucial in peripheral arterial disease. Choice B may improve circulation, but it does not address foot care directly. Choice C can lead to burns or injury due to decreased sensation in peripheral arterial disease. Choice D poses a risk of injury or infection due to the potential for skin damage while soaking the feet. Overall, choice A is the most appropriate for maintaining foot health in peripheral arterial disease.
A nurse is caring for a client who has tuberculosis. Which of the following precautions should the nurse implement for this client?
- A. Standard precautions
- B. Airborne precautions
- C. Contact precautions
- D. Droplet precautions
Correct Answer: B
Rationale: The correct answer is B: Airborne precautions. Tuberculosis is transmitted through the air via droplet nuclei. Implementing airborne precautions includes wearing an N95 respirator, placing the client in a negative pressure room, and ensuring proper ventilation. Standard precautions (A) are for all clients, contact precautions (C) are for direct contact with the client or their environment, and droplet precautions (D) are for pathogens transmitted through respiratory droplets. Therefore, implementing airborne precautions is crucial to prevent the spread of tuberculosis.