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Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?
- A. Measure the client's vital signs.
- B. Assess the client's pain level.
- C. Verify the morphine order with another nurse.
- D. Check the client's last dose of morphine.
Correct Answer: A
Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.
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The healthcare professional is assessing a client who is post-operative following abdominal surgery. Which assessment finding would require immediate intervention?
- A. Absent bowel sounds
- B. Pain level of 8/10
- C. Temperature of 100.4°F
- D. Saturated abdominal dressing
Correct Answer: D
Rationale: A saturated abdominal dressing may indicate active bleeding or other complications that require immediate intervention. This finding suggests a potential surgical site issue that needs urgent attention to prevent further complications. Absent bowel sounds, pain level, and a slightly elevated temperature are common post-operative findings that may not necessarily require immediate intervention compared to a saturated abdominal dressing. Absent bowel sounds can be common after surgery due to anesthesia but may resolve with time. Pain and slightly elevated temperature are expected post-operative findings that can be managed with appropriate pain relief and monitoring. However, a saturated abdominal dressing indicates a potential ongoing issue at the surgical site that needs prompt assessment and intervention to prevent complications.
A client has an indwelling urinary catheter. Which of the following assessment findings indicates that the catheter requires irrigation?
- A. Bladder scan shows 525 mL of urine
- B. Urine has a strong odor
- C. The client reports abdominal discomfort
- D. The catheter is blocked or not draining
Correct Answer: D
Rationale: The correct answer is D because if the catheter is blocked or not draining, it may need irrigation to restore proper flow. Option A, 'Bladder scan shows 525 mL of urine,' does not necessarily indicate the need for irrigation as it could be within the expected range for catheter drainage. Option B, 'Urine has a strong odor,' may indicate a urinary tract infection but does not directly correlate with the need for catheter irrigation. Option C, 'The client reports abdominal discomfort,' could indicate various issues but does not specifically suggest the need for catheter irrigation.
A nurse in a provider's office is preparing to assess a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect?
- A. Concave thoracic spine posteriorly
- B. Exaggerated lumbar curvature
- C. Concave lumbar spine posteriorly
- D. Exaggerated thoracic curvature
Correct Answer: B
Rationale: When assessing a young adult's musculoskeletal system, the nurse should expect an exaggerated lumbar curvature (lordosis). This is a normal finding in young adults due to the natural curvature of the spine. Concave thoracic spine posteriorly (choice A) and concave lumbar spine posteriorly (choice C) are not typical findings as the spine should have normal curvatures. Exaggerated thoracic curvature (choice D) is also not a typical finding in young adults.
A child is postoperative following a tonsillectomy. Which of the following actions should the nurse take?
- A. Administer analgesics to the child on a routine schedule throughout the day and night.
- B. Offer fluids to the child immediately after surgery.
- C. Allow the child to return to solid foods gradually.
- D. Avoid administering any medication until the child is fully awake.
Correct Answer: A
Rationale: Administering analgesics to the child on a routine schedule throughout the day and night is crucial for managing postoperative pain effectively and ensuring the child's comfort. Pain management is a priority in the postoperative period to promote healing and prevent complications. Offering fluids to the child immediately after surgery (Choice B) is essential to prevent dehydration, but pain control takes precedence. Allowing the child to return to solid foods gradually (Choice C) is important, but initially, the child may need to start with clear liquids and progress to soft foods post-tonsillectomy. Avoiding administering any medication until the child is fully awake (Choice D) is not advisable because timely pain relief is essential for the child's comfort and recovery.
A client with rheumatoid arthritis is prescribed prednisone. What information should the LPN/LVN include when teaching the client about this medication?
- A. Take the medication with food to minimize gastrointestinal side effects.
- B. Avoid exposure to sunlight while taking this medication.
- C. Do not discontinue the medication abruptly.
- D. Increase fluid intake while taking this medication.
Correct Answer: C
Rationale: The correct answer is C: 'Do not discontinue the medication abruptly.' It is crucial for clients prescribed prednisone to not stop the medication suddenly to prevent adrenal insufficiency, as this medication suppresses the body's natural production of cortisol. Choice A is incorrect because prednisone should be taken with food to minimize gastrointestinal side effects, not necessarily to prevent stomach upset. Choice B is incorrect as there is no specific need to avoid sunlight while taking prednisone. Choice D is not directly related to prednisone use; while adequate fluid intake is generally beneficial, it is not a specific instruction for prednisone administration.