Nokea
An older adult client returns to the clinic for chronic pain management after taking morphine sulfate 25 mg PO every 12 hours. The client reports taking the medication only when the pain was too severe to sleep. Which action should the nurse implement?
- A. Teach the client alternative ways to manage chronic pain.
- B. Instruct the client to take the morphine sulfate every 12 hours as prescribed.
- C. Tell the client to continue taking the morphine sulfate with severe pain.
- D. Explain the risk of drug addiction from long-term pain medications.
Correct Answer: B
Rationale: Scheduled dosing maintains consistent pain control.
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The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and has the client's toenails?
- A. Shufling gait.
- B. Urinary incontinence.
- C. Syncope when bending.
- D. Hand tremors.
Correct Answer: A,C,D
Rationale: Mobility and dexterity issues necessitate foot care assistance.
After obtaining an oxygen saturation level of 94% for a client with pneumonia who is receiving oxygen via nasal cannula at 3 L/minute, the nurse observes a red mark on the client's right cheek. Which intervention should the nurse implement?
- A. Discontinue the use of the nasal cannula.
- B. Apply lubricant to the cannula tubing.
- C. Place padding around the cannula tubing.
- D. Decrease the flow rate to 1 L/minute.
Correct Answer: C
Rationale: Padding prevents skin breakdown.
During the admission assessment to the hospital, an adult client reports being allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
- A. Secure an allergy bracelet around the client's wrist.
- B. Notify the dietary department of the client's fruit allergy.
- C. Send a list of medication allergies to the pharmacy.
- D. Place a latex-free supply cart outside the client's room.
Correct Answer: A
Rationale: Allergy bracelet prevents immediate exposure.
The nurse is preparing an in-service on the Health Insurance Portability and Accountability Act (HIPAA) violations. Which example should the nurse use to demonstrate a HIPAA violation?
- A. Describing a client's illness in the breakroom without mentioning a name.
- B. Discussing health history with the client behind a closed curtain.
- C. Faxing health records to the client's primary healthcare provider.
- D. Sharing a client's discharge needs with other treatment team members.
Correct Answer: A
Rationale: Public discussion risks confidentiality breach.
To assess a client's dorsalis pedis pulse, the nurse applies firm pressure over the top of the foot between the extension tendons of the great and first toes but does not feel a pulsation. Which action should the nurse take next?
- A. Reduce the amount of pressure being applied on the top of the foot.
- B. Document in the nurse's notes that the dorsalis pedis pulse is not palpable.
- C. Obtain a Doppler stethoscope to auscultate the pulse at the same site.
- D. Palpate the site on the inner side of the ankle below the medial malleolus.
Correct Answer: C
Rationale: Doppler detects weak pulses.