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A nurse suspects that a coworker is diverting opioid analgesics. Which of the following is an adverse effect of opioid medications?
- A. Dilated pupils
- B. Euphoria
- C. Rhinorrhea
- D. Hallucinations
Correct Answer: B
Rationale: The correct answer is B: Euphoria. Opioid medications can cause euphoria as they act on the brain's reward system, leading to feelings of pleasure and well-being. This can contribute to their potential for misuse and diversion. Dilated pupils (A) are a common side effect of opioid use, not an adverse effect. Rhinorrhea (C) refers to a runny nose and is not typically associated with opioid use. Hallucinations (D) are rare but possible with high doses or in susceptible individuals. In summary, euphoria is a known adverse effect of opioid medications, making it the correct choice.
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A nurse is conducting a performance evaluation for an assistive personnel (AP). Which of the following actions by the AP should the nurse identify as requiring further training?
- A. The AP checks a client's identification band before providing a meal tray.
- B. The AP reports a client's complaint of pain to the nurse immediately.
- C. The AP uses an alcohol-based hand rub after assisting a client with ambulation.
- D. The AP leaves a client's bed in the lowest position without raising side rails for a client at risk for falls.
Correct Answer: D
Rationale: The correct answer is D. Leaving a client's bed in the lowest position without raising side rails for a client at risk for falls is a safety violation. The nurse should identify this action for further training because it puts the client at risk of injury. Lowering the bed and raising side rails are essential fall prevention measures. Checking the client's identification band (A) ensures correct client identification. Reporting client complaints of pain (B) promptly is important for timely intervention. Using hand rub after assisting a client (C) promotes infection control. Options E, F, and G are not provided in the question. In summary, choice D is correct as it pertains to client safety, while the other options demonstrate appropriate nursing actions.
A nurse is leading a debriefing session after a critical incident on the unit. Which of the following actions should the nurse take to support the team?
- A. Focus on assigning blame for the incident.
- B. Encourage staff to share their feelings and experiences.
- C. Criticize staff for errors made during the incident.
- D. Limit the discussion to procedural changes only.
Correct Answer: B
Rationale: Encouraging staff to share their feelings and experiences promotes emotional support and team cohesion, helping staff process the incident and identify areas for improvement.
An RN is making nursing staff assignments for his team consisting of himself, two licensed practical nurses (LPNs), and an assistive personnel (AP). Which of the following clients should he assume responsibility for?
- A. The client who is in protective isolation
- B. The client who is actively dying and requires IV pain medication
- C. The client who is 3 days postoperative and requires a dressing change
- D. The client who requires frequent ambulation
Correct Answer: B
Rationale: The correct answer is B: The client who is actively dying and requires IV pain medication. The RN should assume responsibility for this client because as the registered nurse, they are the most qualified to manage complex care needs, such as IV pain medication administration and end-of-life care. The RN's advanced knowledge and skills make them best suited to provide appropriate assessment, intervention, and coordination of care in this critical situation.
Choice A is incorrect because the client in protective isolation requires meticulous adherence to infection control practices, which can be safely delegated to the LPNs or AP under the RN's supervision.
Choice C is incorrect as a dressing change for a client 3 days postoperative is within the scope of practice for the LPNs or AP and does not require the RN's direct involvement.
Choice D, the client requiring frequent ambulation, can be delegated to the LPNs or AP, as this task does not require the RN's specialized skill set.
A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the following clients is the nurse's priority?
- A. A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6
- B. A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous
- C. A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post-meal capillary blood glucose is now 160 mg/dL
- D. A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg
Correct Answer: D
Rationale: The correct answer is D. The nurse's priority is the client whose blood pressure dropped significantly from 138/86 mm Hg to 106/60 mm Hg. This indicates a potential issue with perfusion and could be a sign of hypovolemic shock, which is a life-threatening condition requiring immediate intervention to prevent further complications. Monitoring and addressing this client's blood pressure is crucial to prevent deterioration.
Choice A is not the priority because pain management can be addressed after ensuring the client's physiological stability.
Choice B indicates a normal progression in wound healing and does not require immediate attention.
Choice C, while showing an increase in blood glucose levels, does not pose an immediate threat to the client's health compared to a significant drop in blood pressure as in Choice D.
A nurse is assessing a group of clients for hospice services. The nurse should recommend hospice care for which of the following clients?
- A. A client who has diabetes mellitus and is having difficulty self-administering insulin because of poor eye sight
- B. A client who has terminal cancer and needs assistance with pain management
- C. A client who has dementia and needs help with activities of daily living
- D. A client who is recovering from a stroke and needs someone to provide care while his spouse is at work
Correct Answer: B
Rationale: The correct answer is B because hospice care is appropriate for clients with terminal illnesses who require palliative care, such as pain management. This client's terminal cancer indicates a need for hospice services to provide comfort and support during end-of-life care. Choices A, C, and D do not meet the criteria for hospice care as they do not involve terminal illness requiring palliative care. Choice A's issue can be managed with assistance, choice C's issue is related to dementia care, and choice D's issue is related to post-stroke care.