Nokea
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.
You may also like to solve these questions
A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?
- A. Comatose, breathing unlabored
- B. Glasgow Coma Scale 8, respirations regular
- C. Appears to be sleeping, vital signs stable
- D. Glasgow Coma Scale 13, no ventilator required
Correct Answer: B
Rationale: The correct answer is B: 'Glasgow Coma Scale 8, respirations regular.' A Glasgow Coma Scale of 8 with regular respirations accurately describes a non-responsive state with independent breathing. Choice A is incorrect because 'comatose' implies a deep state of unconsciousness, which may not be accurate in this case. Choice C is incorrect as stating the client 'appears to be sleeping' may not accurately reflect the severity of the situation. Choice D is incorrect because a Glasgow Coma Scale of 13 would not typically correspond to a non-responsive state.
What action should a healthcare professional planning to insert an IV for an older adult client take?
- A. Place the client's arm in a dependent position.
- B. Place the client's arm in a flexed position.
- C. Elevate the client's arm to the level of the heart.
- D. Use a tourniquet above the insertion site.
Correct Answer: A
Rationale: The correct action for a healthcare professional planning to insert an IV for an older adult client is to place the client's arm in a dependent position. This positioning helps with vein prominence and facilitates easier IV insertion by enhancing blood flow and distending the veins. Placing the arm in a flexed position or elevating it to the level of the heart can impede vein visualization and make insertion more challenging. Using a tourniquet above the insertion site is a step in the IV insertion process but is not the initial action to take when preparing for the procedure.
A client with osteoporosis is prescribed alendronate (Fosamax). What instruction should the LPN/LVN provide to the client?
- A. Take the medication with a full glass of water.
- B. Take the medication at bedtime.
- C. Take the medication with food.
- D. Take the medication on an empty stomach.
Correct Answer: A
Rationale: The correct instruction for a client prescribed alendronate (Fosamax) is to take the medication with a full glass of water. Alendronate can cause irritation to the esophagus, so it is important to take it with a full glass of water and remain upright for at least 30 minutes after taking the medication to help prevent this irritation. Taking the medication at bedtime (choice B) may increase the risk of esophageal irritation as lying down can allow the medication to remain in the esophagus longer. Taking the medication with food (choice C) or on an empty stomach (choice D) can also interfere with the absorption of alendronate, reducing its effectiveness in treating osteoporosis.
A client who is postoperative is using an incentive spirometer. Into which of the following positions should the nurse place the client?
- A. Side-lying
- B. Supine
- C. Semi-Fowler's
- D. Trendelenburg
Correct Answer: C
Rationale: The correct position for a postoperative client using an incentive spirometer is the Semi-Fowler's position. Placing the client in Semi-Fowler's or high-Fowler's position maximizes lung expansion and the effectiveness of the incentive spirometer. Side-lying may not provide optimal lung expansion. The supine position is not ideal for postoperative clients using incentive spirometers as it may limit lung expansion. The Trendelenburg position is not recommended due to potential complications postoperatively.
When admitting a 5-month-old who has vomited 9 times in the past 6 hours, what should the healthcare provider observe for signs of which overall imbalance?
- A. Metabolic acidosis
- B. Metabolic alkalosis
- C. Increased serum hemoglobin levels
- D. Decreased serum potassium levels
Correct Answer: B
Rationale: When a 5-month-old infant vomits multiple times, there is a risk of developing metabolic alkalosis due to the loss of stomach acid. Metabolic alkalosis is characterized by elevated pH and bicarbonate levels. It is caused by the loss of hydrogen ions from the body, often through vomiting. Metabolic acidosis (choice A) is unlikely in this scenario because it is more commonly associated with conditions like renal failure or diabetic ketoacidosis. Choice C, increased serum hemoglobin levels, is not typically a direct consequence of vomiting. Choice D, decreased serum potassium levels, may occur with vomiting but is not the primary concern when a patient is vomiting excessively.