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An elderly client is admitted with an acute exacerbation of chronic obstructive pulmonary disease. Pulse oximetry is 84% on room air. The client is restless, has expiratory wheezing and a productive cough, and is using the accessory muscles to breathe. Which prescription should the nurse question?
- A. Albuterol 2.5 mg by nebulizer
- B. IV methylprednisolone 125 mg now and every 6 hours
- C. IV morphine 2 mg now, may repeat every 2 hours
- D. Oxygen at 2 L/min by nasal cannula
Correct Answer: C
Rationale: Morphine (C) can depress respiration in COPD, worsening hypoxia, and should be questioned. Albuterol (A) relieves bronchospasm, methylprednisolone (B) reduces inflammation, and oxygen (D) addresses hypoxia, all appropriate for COPD exacerbation.
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The nurse has delegated the task of taking the temperature of a client with a new tympanic thermometer to a certified nursing assistant. The nursing assistant says, 'This looks easy. I am good at figuring things out.' What is the nurse's responsibility?
- A. Allow the nursing assistant to proceed.
- B. Assign the task to another nursing assistant.
- C. Ask another nursing assistant to demonstrate this task to the nursing assistant.
- D. Demonstrate the proper use of the thermometer and observe the nursing assistant.
Correct Answer: D
Rationale: Demonstrating and observing ensures the CNA uses the tympanic thermometer correctly, maintaining accuracy and safety.
The nurse is preparing to administer medications to a client with acute decompensated heart failure. Which of the following medications should the nurse hold for clarification prior to administering?
- A. atorvastatin
- B. enoxaparin
- C. furosemide
- D. metoprolol
Correct Answer: D
Rationale: Metoprolol (D) may worsen acute decompensated heart failure by reducing cardiac output, requiring clarification. Furosemide (C) treats fluid overload, enoxaparin (B) prevents thrombosis, and atorvastatin (A) manages lipids.
A nurse manager considers changing staff assignments from 8 hour shifts to 12 hour shifts. A staff-selected planning committee has approved the change, yet the staff are not receptive to the plan. As a change agent, the nurse manager should first
- A. support the planning committee and post the new schedule
- B. explore how the planning committee evaluated barriers to the plan
- C. design a different approach to deliver care with fewer staff
- D. retain the previous staffing pattern for another 6 months
Correct Answer: B
Rationale: The manager is ultimately responsible for delivery of care and yet has given a committee chosen by staff the right to approve or disapprove the change. Planned change involves exploring barriers and restraining forces before implementing change. To smooth acceptance of the change, restraining factors need to be evaluated.
The nurse caring for a terminally ill client asks if the client has an advance directive. The client states, 'I already have a power of attorney.' What is the best response by the nurse?
- A. A power of attorney (POA) is good to have in place. It sounds like you are on the right track.
- B. Great. Your POA can start to make decisions for you when you are no longer able to do so.
- C. Many people find a lawyer at this stage of life. A lawyer can help you get your affairs in order.
- D. There are many types of POAs. Let's clarify if your POA can make health care decisions for you.
Correct Answer: D
Rationale: Clarifying if the POA includes healthcare decisions (D) ensures proper advance directive planning. Vague affirmations (A, B) or suggesting a lawyer (C) do not address the need for a healthcare-specific POA.
The nurse is reviewing a nutritional plan for a 6-month-old who has recently been started on solid foods. Which of the following recommendations has the highest priority in the plan?
- A. Canned baby food is more expensive than food prepared at home
- B. Finger foods can be introduced before the child has teeth
- C. New foods should be introduced at least 5-7 days apart
- D. Rice cereal can be mixed with cow's milk to increase nutritional intake
Correct Answer: C
Rationale: Introducing new foods 5-7 days apart (C) prevents allergic reactions by identifying triggers, making it the priority. Cost (A), finger foods (B), and cow's milk (D, not recommended before 12 months) are secondary.