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A physician has written an order for '2.0 mg MS q 2-4 hr prn pain.' What is the nurse's appropriate response to this order?
- A. Give 2 mg of morphine sulfate to the client
- B. Give 20 mg of morphine sulfate to the client
- C. Contact the pharmacy to clarify the order
- D. Contact the physician to rewrite the order
Correct Answer: D
Rationale: The correct answer is D: Contact the physician to rewrite the order. The order '2.0 mg MS q 2-4 hr prn pain' is ambiguous as it does not specify the maximum dose within the 2-4 hour range. The nurse should clarify with the physician to ensure patient safety and accuracy in medication administration. Option A is incorrect as it assumes the dose without clarification. Option B is incorrect as it provides an incorrect dose. Option C is not the most appropriate initial action as contacting the physician directly is crucial.
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Which of the following types of antipsychotic medications is most likely to produce extrapyramidal effects?
- A. Atypical antipsychotic drugs
- B. First-generation antipsychotic drugs
- C. Third-generation antipsychotic drugs
- D. Dopamine system stabilizers
Correct Answer: B
Rationale: The correct answer is B: First-generation antipsychotic drugs. These medications primarily block dopamine receptors in the brain, leading to extrapyramidal effects such as dystonia, akathisia, parkinsonism, and tardive dyskinesia. These side effects are less common with atypical antipsychotic drugs (choice A) due to their different receptor profiles. Third-generation antipsychotic drugs (choice C) and dopamine system stabilizers (choice D) are newer classes of medications with reduced extrapyramidal effects compared to first-generation drugs. Therefore, the most likely culprit for producing extrapyramidal effects among the options provided is the first-generation antipsychotic drugs.
A 39-year-old woman presents for treatment of excessive vaginal bleeding after giving birth to twins one week ago. Which nursing diagnosis is most appropriate in this situation?
- A. Knowledge Deficit related to post-partum blood loss
- B. Self-Care Deficit related to post-partum neglect
- C. Fluid Volume Deficit related to post-partum hemorrhage
- D. Body Image Disturbance related to body changes after delivery
Correct Answer: C
Rationale: The correct answer is C: Fluid Volume Deficit related to post-partum hemorrhage. This nursing diagnosis is most appropriate because excessive vaginal bleeding can lead to a significant loss of blood volume, potentially resulting in hypovolemia. It is crucial to address this issue promptly to prevent further complications. Choice A is incorrect as the primary concern is the fluid volume deficit, not knowledge deficit. Choice B is incorrect as self-care deficit is not the priority in this situation. Choice D is incorrect as body image disturbance is not directly related to the excessive bleeding.
Mr. W has orders for a physical therapy consult. The nurse contacts the appropriate department but 12 hours later, no one has come to see the client. Which is the most appropriate action of the nurse?
- A. Call the supervisor and file a complaint against the physical therapy department
- B. Contact the physician to notify him that the orders were not carried out
- C. Assess the client's activity level by assisting with ambulation using a gait belt
- D. Contact the physical therapy department again and repeat the order
Correct Answer: D
Rationale: The most appropriate action for the nurse in this scenario is to contact the physical therapy department again and repeat the order (Choice D). This is the correct answer because it directly addresses the issue of the consult not being completed within a reasonable timeframe. By contacting the department again, the nurse ensures that the order is not overlooked or forgotten. This action shows proactive communication and follow-up to expedite the process and ensure the client receives the necessary care in a timely manner.
The other choices are incorrect:
A: Calling the supervisor and filing a complaint is premature without first attempting to resolve the issue directly with the department.
B: Contacting the physician is not the nurse's role in this situation. The focus should be on coordinating with the appropriate department.
C: Assessing the client's activity level is important but does not address the primary issue of the physical therapy consult not being completed.
Overall, choice D is the most appropriate course of action in this scenario.
A client is refusing to undergo any more treatments in the hospital and wants to leave against medical advice. When the nurse requests the client to sign an AMA order, the client refuses and leaves. What is the next action of the nurse?
- A. Call security to hold the client until he signs the order
- B. Notify the physician to convince the client to stay
- C. Speak with the client's spouse to persuade him to stay
- D. Allow the client to leave and document the refusal in his chart
Correct Answer: D
Rationale: The correct answer is D: Allow the client to leave and document the refusal in his chart. This is the appropriate action because every individual has the right to refuse medical treatment, even if it is against medical advice. By allowing the client to leave and documenting the refusal in the chart, the nurse respects the client's autonomy and ensures legal and ethical considerations are met. Calling security to hold the client (choice A) would violate the client's rights. Notifying the physician to convince the client (choice B) may not be effective and goes against the client's autonomy. Speaking with the client's spouse (choice C) is irrelevant as the decision lies with the client.
Examples of preservation of self-integrity include all of the following except:
- A. Using assistive equipment to move bariatric clients
- B. Participating in wellness programs
- C. Accepting the challenge of caring for clients with oppositional beliefs or practices
- D. Using hand hygiene and personal protective equipment
Correct Answer: C
Rationale: The correct answer is C: Accepting the challenge of caring for clients with oppositional beliefs or practices. This choice does not align with preservation of self-integrity as it may require compromising personal values or beliefs. Using assistive equipment (A) promotes safety, participating in wellness programs (B) supports personal well-being, and using hand hygiene and PPE (D) ensures infection control. Accepting clients' opposing beliefs may lead to internal conflict, compromising self-integrity.