Nokea
A patient before administration of morphine sulfate 8 mg IM q 3-4 hours for pain PRN.
In which of the following situations should the nurse consider withholding the medication until further assessment is done?
- A. The patient complains of acute pain from a second-degree burn affecting the lower left leg.
- B. The patient's blood pressure is 140/90, pulse is 90, and respiration is 28.
- C. The patient's level of consciousness fluctuates from alert to lethargic.
- D. The patient exhibits restlessness, anxiety, and cold, clammy skin.
Correct Answer: C
Rationale: Strategy: Determine the significance of each answer choice and how it relates to morphine. (1) morphine used for moderate to severe pain, medication should be given (2) BP slightly elevated, respirations elevated, may be the result of pain, medication should be given (3) correct-morphine depresses CNS, especially respiratory center in medulla (4) may be the result of pain
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When an autistic client begins to eat with her hands, the nurse can best handle the problem by
- A. Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.'
- B. Commenting, 'I believe you know better than to eat with your hand.'
- C. Jokingly stating, 'Well I guess fingers sometimes work better than spoons.'
- D. Removing the food and stating, 'You can't have anymore food until you use the spoon.'
Correct Answer: A
Rationale: Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.' This provides clear instruction and encourages adaptive behavior.
The nurse is caring for a client receiving chemotherapy who is experiencing neutropenia. Which intervention would be most appropriate to recommend for inclusion in the client's plan of care?
- A. Assess the client's temperature every 4 hours due to risk of hypothermia.
- B. Instruct the client to avoid large crowds and people who are sick.
- C. Instruct the client in the use of a soft toothbrush.
- D. Assess the client for hematuria.
Correct Answer: B
Rationale: Neutropenia increases the risk of infection due to low neutrophil counts. Avoiding large crowds and sick individuals minimizes exposure to pathogens, making B the most appropriate intervention. Answer A is incorrect as hypothermia is not a primary concern. Answer C, while relevant for preventing mucosal bleeding, is less critical than infection prevention. Answer D is unrelated to neutropenia.
A client is admitted to the hospital with findings of liver failure with ascites. The health care provider orders spironolactone (Aldactone). What is the pharmacological effect of this medication?
- A. Promotes sodium and chloride excretion
- B. Increases aldosterone levels
- C. Depletes potassium reserves
- D. Combines safely with antihypertensives
Correct Answer: A
Rationale: Spironolactone promotes sodium and chloride excretion while sparing potassium and decreasing aldosterone levels. It has no effect on ammonia levels.
A client has a cataract removed from the left eye. Which of the following is an important nursing intervention in the immediate postoperative period?
- A. Position the client on the right side with the head slightly elevated.
- B. Place the client on the left side to protect the eye.
- C. Perform sensory neurological checks every two hours.
- D. Maintain complete bedrest for the first 48 hours.
Correct Answer: A
Rationale: Positioning on the right side with head elevation prevents pressure on the surgical eye, reducing complications. Options B, C, and D are incorrect.
The nurse is caring for a client with chronic kidney disease who is receiving epoetin alfa (Epogen). Which of the following laboratory results should the nurse report immediately?
- A. Hemoglobin 14 g/dL.
- B. Potassium 4.5 mEq/L.
- C. Creatinine 3.0 mg/dL.
- D. Calcium 9.0 mg/dL.
Correct Answer: A
Rationale: A hemoglobin of 14 g/dL is too high, risking hypertension or thrombosis with epoetin alfa. Options B, C, and D are expected or normal.