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In caring for a client with a PCA infusion of morphine sulfate through the right cephalic vein, the nurse assesses that the client is lethargic with a blood pressure of 90/60 mm Hg, a pulse rate of 118 beats per minute, and a respiratory rate of 8 breaths per minute. What assessment should the nurse perform next?
- A. Note the appearance and patency of the client's peripheral IV site.
- B. Palpate the volume of the client's right radial pulse.
- C. Auscultate the client's breath sounds bilaterally.
- D. Observe the amount and dose of morphine in the PCA pump syringe.
Correct Answer: D
Rationale: In this scenario, the client is presenting with signs of potential opioid overdose, such as lethargy, hypotension, tachycardia, and bradypnea. The next assessment the nurse should perform is to observe the amount and dose of morphine in the PCA pump syringe. This evaluation is crucial in determining if the client is receiving an excessive amount of morphine, leading to the observed symptoms. Checking the PCA pump syringe will provide essential information to address the client's condition promptly and prevent further complications. Choices A, B, and C are not the priority in this situation as they do not directly address the potential cause of the client's symptoms related to morphine administration.
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The healthcare provider prescribes an IV solution of isoproterenol (Isuprel) 1 mg in 250 ml of D5W at 300 mcg/hour. The nurse should program the infusion pump to deliver how many ml/hour?
- A. 50 ml/hour
- B. 25 ml/hour
- C. 75 ml/hour
- D. 100 ml/hour
Correct Answer: C
Rationale: To calculate the infusion rate, convert 1 mg to 1,000 mcg (1 mg = 1,000 mcg) and then use the formula D/H x Q, where D is the desired dose, H is the dose on hand, and Q is the quantity of solution. In this case, it would be 300 mcg/hour / 1,000 mcg x 250 ml = 75 ml/hour. Therefore, the nurse should program the infusion pump to deliver 75 ml/hour. Choice A (50 ml/hour), Choice B (25 ml/hour), and Choice D (100 ml/hour) are incorrect as they do not correspond to the calculated rate of 75 ml/hour.
The nurse observes an unlicensed assistive personnel (UAP) using an alcohol-based gel hand cleaner before performing catheter care. The UAP rubs both hands thoroughly for 2 minutes while standing at the bedside. What action should the nurse take?
- A. Encourage the UAP to remain in the client's room until the hand rub is completed.
- B. Explain that the hand rub can be completed in less than 2 minutes.
- C. Inform the UAP that handwashing helps to promote better asepsis.
- D. Determine why the UAP was not wearing gloves in the client's room.
Correct Answer: B
Rationale: The correct answer is B. Alcohol-based hand rubs are effective with a shorter rub time, typically around 20-30 seconds. Standing at the bedside for 2 minutes to rub hands thoroughly is unnecessary and can lead to wastage of resources. It's essential for the nurse to educate the UAP on proper hand hygiene techniques to ensure efficient and effective infection control practices. Choices A, C, and D are incorrect because encouraging the UAP to remain in the client's room, discussing handwashing instead of hand rubs, and questioning glove use are not the most appropriate actions in this scenario.
A newly graduated female staff nurse requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?
- A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
- B. I know you are a good nurse and can handle this client in a professional manner.
- C. I'll talk to the client about his behavior and insist that he stop it immediately.
- D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.
Correct Answer: D
Rationale: The best response for the nurse manager to provide in this situation is option D, which involves changing the assignment to address the nurse's immediate concern. It also offers an opportunity to have a conversation with the nurse about how to professionally handle such situations in the future. Option A is not the best response as it does not address the underlying issue and simply shifts the problem to another staff member. Option B, while supportive, does not actively address the client's inappropriate behavior. Option C is not ideal as the nurse manager should handle discussions about inappropriate behavior with clients themselves rather than delegating it to the staff nurse.
A female client reports that her hair is becoming coarse and breaking off, the outer part of her eyebrows has disappeared, and her eyes are all puffy. Which follow-up question is best for the nurse to ask?
- A. Is there a history of female baldness in your family?
- B. Are you under any unusual stress at home or work?
- C. Do you work with hazardous chemicals?
- D. Have you noticed any changes in your fingernails?
Correct Answer: D
Rationale: The correct answer is D because the manifestations reported by the client, such as coarse hair, missing eyebrows, and puffy eyes, are indicative of hypothyroidism. Changes in the fingernails, such as brittle or pitted nails, can also be associated with hypothyroidism. Option A is incorrect as female baldness is not directly related to the reported symptoms. Option B is less relevant as stress typically does not cause these specific symptoms. Option C is also less relevant as exposure to hazardous chemicals would present with different symptoms.
Which statement by the client indicates an understanding of the dietary modifications required with Cushing syndrome?
- A. I should increase my intake of foods high in calcium.
- B. I should avoid foods with high sodium content.
- C. I need to decrease my intake of vitamin D.
- D. I should consume more potassium-rich foods.
Correct Answer: B
Rationale: The correct answer is B: 'I should avoid foods with high sodium content.' Clients with Cushing syndrome need to limit their sodium intake to help reduce fluid retention and manage hypertension, which are common complications of the syndrome. Increasing calcium intake (choice A) is not specifically indicated for Cushing syndrome. Decreasing vitamin D intake (choice C) is not a typical dietary modification for this condition. Consuming more potassium-rich foods (choice D) is not a primary focus of dietary modifications for Cushing syndrome.