Nokea
A nurse is to administer 10 mg of morphine sulfate to a client with three fractured ribs. The available concentration for this drug is 15 mg/mL. How many milliliters should the nurse administer? Round to one decimal point.
Correct Answer: 0.7 mL
Rationale: To calculate: 10 mg ÷ 15 mg/mL = 0.666€¦ mL, rounded to 0.7 mL.
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Which of the following actions should the nurse plan to do first when caring for a client who is experiencing spiritual distress?
- A. Make a referral to a member of the clergy.
- B. Explain the major beliefs of different religions.
- C. Suggest reading material.
- D. Help the client explore his or her own values and beliefs.
Correct Answer: D
Rationale: Helping the client explore their own values and beliefs is the first step in addressing spiritual distress, as it establishes a foundation for personalized spiritual support.
The nurse teaches a client with chronic obstructive pulmonary disease for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan?
- A. Clubbing of nail beds.
- B. Hypertension.
- C. Peripheral edema.
- D. Increased appetite.
Correct Answer: C
Rationale: Right-sided heart failure (cor pulmonale) in COPD causes peripheral edema due to increased venous pressure. Clubbing reflects chronic hypoxia, not heart failure. Hypertension and increased appetite are unrelated.
A client had a repair of a thoracoabdominal aneurysm 2 days ago. Which of the following findings should the nurse consider unexpected and report to the physician immediately? The client has:
- A. Abdominal pain at 5 on a scale of 0 to 10 for the last 2 days
- B. Heart rate of 100 beats per minute after ambulating 200 feet
- C. Urine output of 2,000 mL in 24 hours
- D. Weakness and numbness in the lower extremities
Correct Answer: D
Rationale: Weakness and numbness in the lower extremities post-thoracoabdominal aneurysm repair suggest spinal cord ischemia or graft-related complications, requiring immediate reporting. Persistent pain, elevated heart rate post-ambulation, and normal urine output are expected or less urgent.
A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order should the nurse assess these clients?
- A. A client with an endotracheal tube transferred out of the intensive care unit that day.
- B. A client with type 2 diabetes who had a cerebrovascular accident 4 days ago.
- C. A client with cellulitis of the left lower extremity with a fever of 100.8°F (38.2°C).
- D. A client receiving D5W I.V. at 125 mL/hour with 75 mL remaining.
Correct Answer: A,C,B,D
Rationale: The client with a new endotracheal tube (A) is highest priority due to airway risk. The febrile client with cellulitis (C) is next for infection monitoring. The stroke client (B) is stable 4 days post-event. The I.V. fluid client (D) is lowest priority.
On the fourth day after surgery, a client has a postoperative wound infection. Which of the following should the nurse assess? Select all that apply.
- A. Total white blood count (WBC) 10,000/mm³.
- B. Redness and swelling beyond the incision line.
- C. Temperature of 102°F (38.9°C).
- D. Client reports of pain at the incision site.
- E. Warmth at the incision site.
Correct Answer: B,C,D,E
Rationale: Signs of wound infection include redness/swelling (B), fever (C), pain (D), and warmth (E). A WBC of 10,000/mm³ (A) is normal and not indicative of infection.