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A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?
- A. Heart rate of 88/min
- B. Pain rating of 4 on a scale of 0 to 10
- C. Respiratory rate of 10/min
- D. Temperature of 37.2°C (99°F)
Correct Answer: C
Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.
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A nurse working in a rehabilitation facility is developing a discharge plan for a client who has left-sided hemiplegia. Which of the following actions is the nurse's priority?
- A. Consult with a case manager regarding insurance coverage.
- B. Counsel caregivers on respite care options.
- C. Ensure that the client has a referral for physical therapy.
- D. Refer the client to a local stroke support group.
Correct Answer: C
Rationale: The correct answer is C: 'Ensure that the client has a referral for physical therapy.' For a client with left-sided hemiplegia, physical therapy is crucial in restoring function and mobility. It is the nurse's priority to ensure the client receives the necessary rehabilitation services. Consulting with a case manager about insurance coverage (Choice A) is important but not the priority at this stage. Counseling caregivers on respite care options (Choice B) and referring the client to a local stroke support group (Choice D) are also valuable but not as essential as ensuring the client has access to physical therapy for rehabilitation.
A nurse is caring for a client who is receiving warfarin therapy. Which of the following laboratory results indicates the need for an increase in the dose of warfarin?
- A. PT 28 seconds
- B. INR 1.2
- C. aPTT 40 seconds
- D. Fibrinogen 350 mg/dL
Correct Answer: B
Rationale: An INR of 1.2 is below the therapeutic range for a client on warfarin, indicating inadequate anticoagulation. Therefore, the client would require an increase in the dose of warfarin to achieve the desired therapeutic effect. Choices A, C, and D are not indicative of the need for a dose increase in warfarin therapy. PT of 28 seconds is within the therapeutic range, aPTT of 40 seconds is also within the normal range, and fibrinogen level of 350 mg/dL does not provide information about the anticoagulant effect of warfarin.
A client with a new prescription for furosemide should increase intake of which of the following?
- A. You should take this medication on an empty stomach.
- B. You should increase your intake of potassium-rich foods.
- C. You should take this medication at bedtime.
- D. You should avoid taking this medication with food.
Correct Answer: B
Rationale: The correct answer is B: 'You should increase your intake of potassium-rich foods.' Furosemide is a potassium-wasting diuretic, which means it can lead to low potassium levels in the body. Increasing intake of potassium-rich foods helps counteract this effect. Choices A, C, and D are incorrect because furosemide should not necessarily be taken on an empty stomach, at bedtime, or specifically avoided with food.
A client requests the creation of a living will. Which of the following actions should the nurse take?
- A. Schedule a meeting between the hospital ethics committee and the client
- B. Evaluate the client's understanding of life-sustaining measures
- C. Determine the client's preferences about post-mortem care
- D. Request a conference with the client's family
Correct Answer: B
Rationale: The correct action for the nurse to take when a client requests the creation of a living will is to evaluate the client's understanding of life-sustaining measures. This step is crucial to ensure that the client is well-informed about their options before making decisions regarding their future care. Scheduling a meeting with the hospital ethics committee (choice A) may not be necessary at this stage and could overwhelm the client. Determining the client's preferences about post-mortem care (choice C) is not directly related to creating a living will. Requesting a conference with the client's family (choice D) may be important later but is not the initial step in this situation.
A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?
- A. Insert the catheter 7.5 cm (3 in) into the urethra.
- B. Insert the catheter until urine flow is established.
- C. Cleanse the catheter with sterile water before insertion.
- D. Insert the catheter 5 cm (2 in) into the urethra.
Correct Answer: B
Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.