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A nurse is planning a staff education program to review nursing interventions for clients who have kidney failure. Which of the following sources should the nurse identify as the best resource for obtaining evidence-based information?
- A. The advice of an expert nephrology nurse
- B. Retrospective chart reviews
- C. Facility critical pathway
- D. A recent peer-reviewed nursing research article
Correct Answer: D
Rationale: A peer-reviewed nursing research article is the best resource for obtaining evidence-based information because it provides the most current and reliable data on nursing interventions. Choice A, the advice of an expert nephrology nurse, may be helpful but could be based on individual experience rather than the latest research. Retrospective chart reviews (Choice B) focus on past cases and may not reflect current best practices. Facility critical pathways (Choice C) offer standardized care plans but may not always incorporate the most up-to-date evidence-based practices.
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A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?
- A. Drowsy but responsive when her name is called
- B. SaO2 94%
- C. Respiratory rate 8/min
- D. Pain level of 6 on a scale from 0 to 10
Correct Answer: C
Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.
Which of the following best describes a somatic symptom disorder?
- A. Client experiences sudden onset of symptoms due to stress
- B. Physical manifestations occur due to underlying medical conditions
- C. Client has excessive preoccupation with physical symptoms without a medical cause
- D. Client avoids medical care due to fear of receiving a diagnosis
Correct Answer: C
Rationale: The correct answer is C. Somatic symptom disorder is characterized by individuals having excessive preoccupation with physical symptoms that may or may not have an identifiable medical cause. Choice A is incorrect because the sudden onset of symptoms due to stress is more indicative of acute stress reaction. Choice B is incorrect as it describes physical manifestations related to known medical conditions, not somatic symptom disorder. Choice D is incorrect as it relates to health anxiety or illness anxiety disorder, where individuals avoid seeking medical care due to fear of receiving a diagnosis.
When caring for a client's tracheostomy at home, which instruction should the nurse include in the teaching?
- A. Clean with alcohol
- B. Cover the tracheostomy when outside
- C. Replace the tube weekly
- D. Use tap water to clean
Correct Answer: B
Rationale: Covering the tracheostomy when outside is crucial as it helps prevent dust and other irritants from entering the airway, reducing the risk of complications. Cleaning with alcohol (choice A) can be too harsh for the skin around the tracheostomy site. While replacing the tube weekly (choice C) is important, it is typically done by healthcare providers. Using tap water to clean (choice D) is not recommended as it may introduce contaminants to the tracheostomy site.
A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?
- A. Self-report of pain
- B. Nonverbal behavior
- C. Severity of the condition
- D. Vital signs
Correct Answer: A
Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.
A client who reports insomnia is being taught by a nurse about promoting rest and sleep. Which statement should indicate to the nurse that the client understands the instructions?
- A. I will walk briskly for 30 minutes before bedtime
- B. I will have a cup of hot cocoa immediately before bedtime
- C. I will no longer have a glass of wine before bedtime
- D. I will do my muscle relaxation techniques each afternoon
Correct Answer: C
Rationale: The correct answer is C because avoiding alcohol before bedtime can help promote better sleep. Choice A is incorrect as vigorous exercise close to bedtime can actually hinder sleep. Choice B is also incorrect as consuming beverages with caffeine or sugar close to bedtime can disrupt sleep. Choice D, while a good practice, does not directly address the issue of avoiding alcohol before bedtime to improve sleep quality.