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After abdominal surgery, a client has an order for meperidine (Demerol) I.M. 100 mg every 3 to 4 hours and acetaminophen (Tylenol) with codeine 30 mg. The client has been taking meperidine every 4 hours for the past 48 hours, but she tells the nurse that the meperidine is no longer lasting 4 hours and she needs to have it every 3 hours. Which of the following nursing actions is most appropriate?
- A. Realizing that the client is developing tolerance to the meperidine, the nurse administers the meperidine every 3 hours.
- B. The nurse urges the client to take the acetaminophen with codeine to prevent addiction to the meperidine.
- C. The nurse requests an order from the physician to change the dose to an equianalgesic dose of morphine.
- D. The nurse encourages the client to do relaxation exercises to provide distraction from the pain.
Correct Answer: C
Rationale: Increasing frequency suggests tolerance; switching to an equianalgesic dose of morphine may provide better pain control without escalating doses.
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The nurse is teaching a client with a new diagnosis of asthma about inhaler use. Which of the following instructions should be included for a metered-dose inhaler?
- A. Shake the inhaler before use.
- B. Hold breath for 10 seconds after inhalation.
- C. Rinse the mouth after each use.
- D. Use a spacer if prescribed.
Correct Answer: A, B, D
Rationale: Shaking the inhaler, holding breath, and using a spacer ensure effective medication delivery.
Which site or technique would you expect to use to administer ferrous sulfate?
- A. A subcutaneous injection site
- B. The PQRST technique
- C. The Z track technique
- D. The sublingual site
Correct Answer: C
Rationale: The Z-track technique is used for ferrous sulfate IM injections to prevent leakage and skin staining.
A 10-year-old client with rheumatic fever is on bed rest. Which of the following would be an appropriate diversional activity for the nurse to encourage?
- A. Watching television with his roommate.
- B. Coloring picture books with his brother.
- C. Keeping up with his school work.
- D. Building a bird house.
Correct Answer: B
Rationale: Coloring is a quiet, bed-appropriate activity that engages a 10-year-old without physical exertion, suitable for rheumatic fever recovery.
A client is receiving a continuous infusion of heparin. The nurse notes a partial thromboplastin time (PTT) of 120 seconds. What should the nurse do first?
- A. Stop the infusion
- B. Reduce the infusion rate
- C. Administer protamine sulfate
- D. Notify the physician
Correct Answer: A
Rationale: A PTT of 120 seconds is significantly above the therapeutic range (1.5 to 2 times normal), indicating a risk of bleeding. Stopping the infusion is the first action to prevent harm.
The nurse is assessing a neonate at 5 minutes after birth. The nurse records the Apgar score based on the findings in the chart A. The nurse compares these findings to the Apgar score obtained at birth, as determined by the findings in the chart B. What should the nurse do next?
- A. Notify the neonatologist on call.
- B. Continue to assess the neonate.
- C. Apply an oxygen mask.
- D. Rub the neonate’s extremities.
Correct Answer: B
Rationale: The neonate’s Apgar score has been improving since birth. (The birth score is 6; the current score is 9.) The nurse should continue to assess the neonate. There is no indication that oxygen is
needed since the color is improving, and stimulating the baby is not necessary as the he is now fl exing his extremities.