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An adult male is transferred from post anesthesia care unit (PACU) to the postoperative unit following an internal fixation of a fractured tibia and fibula that occurred during a motor vehicle collision (MVC). The nurse reports that the client received morphine 2 mg intravenously 45 minutes ago and is currently experiencing pain relief of 7 from a previous report of 10. Postoperative prescriptions include, start patient-controlled analgesia (PCA) using hydromorphone 0.2 mg on demand and 0.2 mg/hour basal rate. Which client information should the nurse provide to complete this report?
- A. Police department wants to be notified when the client is alert.
- B. Neurovascular assessments below the fracture are normal.
- C. No nausea or vomiting during the PACU recovery stay.
- D. The family is requesting a private room when one is available.
Correct Answer: B
Rationale: Normal neurovascular assessments are critical to ensure no complications post-surgery.
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An older adult woman with end stage heart disease is alert and oriented and states that she does not want any heroic measures taken in the event she stops breathing. The client's children tell the nurse that they accept their mother's wishes and do not want to watch her suffer. Which action should the nurse take first?
- A. Consult the palliative care team.
- B. Obtain a do not resuscitate prescription.
- C. Define the term heroic measures.
- D. Coordinate a family conference.
Correct Answer: B
Rationale: Obtaining a DNR prescription legally documents the client's wishes, a priority action.
A male client is admitted with difficulty breathing related to a recent diagnosis of metastatic lung cancer. He tells the nurse that he does not want to be 'hooked up to any machines'. His vital signs are heart rate 120 beats/minute, blood pressure 98/50 mm Hg, respirations 30 breaths/minute, and oxygen saturation rate is 88%. Which action should the nurse take?
- A. Obtain the client's legal records for power of attorney.
- B. Ask the palliative care team to speak with the client.
- C. Give analgesic medications as needed (PRN).
- D. Discontinue the intravenous infusion.
Correct Answer: B
Rationale: Consulting palliative care aligns with the client's wishes, focusing on symptom relief and quality of life.
It is most important for the charge nurse to schedule a multi-disciplinary team meeting to discuss which client?
- A. A business executive admitted with Guillain-Barre syndrome who has residual bilateral numbness in the lower extremities.
- B. A woman who is pregnant with twins and whose due date is one week away.
- C. An elderly client admitted through the emergency department with a broken hip whose blood glucose is 400 mg/dL (22 mmol/L).
- D. A 2-year-old who contracted Hepatitis A while at a local daycare center.
Correct Answer: C
Rationale: The elderly client with a broken hip and uncontrolled diabetes requires urgent, coordinated care to manage multiple acute conditions.
Four clients are scheduled to receive IV infusions, but there are only three intravenous (IV) pumps available. Which prescribed infusion can most safely be administered without an IV infusion pump?
- A. Heparin in Normal Saline prescribed for deep vein thrombosis.
- B. Regular Insulin in Normal Saline prescribed for ketoacidosis.
- C. Magnesium in Normal Saline prescribed for hypomagnesemia.
- D. Ceftriaxone in 5% Dextrose in Water prescribed for pneumonia.
Correct Answer: D
Rationale: Ceftriaxone can be safely administered via gravity drip over 30 minutes, unlike high-alert medications like heparin, insulin, or magnesium.
During an evening shift on a medical unit, the only nurse on the unit is busy with an unstable client. The unit clerk, who is also both a certified medication aide and an unlicensed assistive personnel (UAP), reports to the nurse that a healthcare provider is on the telephone and wishes to prescribe an as needed (PRN) dose of an oral over-the-counter laxative for a client who is constipated. Which instruction should the nurse provide the unit clerk?
- A. Tell the healthcare provider the nurse will return the phone call as soon as possible.
- B. Remain with this client and monitor the vital signs while the nurse takes the call.
- C. Ask the healthcare provider to remain on 'hold' until the nurse can confirm the prescription.
- D. Be sure to write down what is prescribed and then repeat it back to the healthcare provider.
Correct Answer: A
Rationale: The nurse must receive prescriptions directly, prioritizing the unstable client's care.