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On the first postoperative day following a bowel resection, the patient complains of abdominal and incisional pain rated 9 on a scale of 0 to 10. Postoperative orders include morphine, 4 mg IV q2 hr, for pain and may repeat morphine, 4 mg IV, for breakthrough pain. The nurse determines that it has been only 2 hours since the last dose of morphine and wants to wait a little longer. What effect does the nurse’s action have on the patient?
- A. Protects the patient from addiction and toxic effects of the drug
- B. Prevents hastening or causing a patient’s death from respiratory dysfunction
- C. Contributes to unnecessary suffering and physical and psychosocial dysfunction
- D. Indicates that the nurse understands the adage of “start low and go slow” in administering analgesics
Correct Answer: C
Rationale: The correct answer is C. Delaying pain relief contributes to unnecessary suffering and can negatively impact recovery.
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For each of the nursing diagnoses listed, identify at least two normal expected physiologic changes related to aging that could be etiologic factors of the diagnosis.
- A. Imbalanced nutrition: less than body requirements
- B. Activity intolerance
- C. Risk for injury
- D. Urge urinary incontinence
Correct Answer: A
Rationale: Aging-related changes include decreased appetite, reduced muscle mass, impaired balance, and increased bladder sensitivity—all contributing to various nursing diagnoses.
Which type of stress helps individuals pursue goals and solve problems?
- A. Energy stress
- B. Active stress
- C. Eustress
- D. Distress
Correct Answer: C
Rationale: Eustress is positive stress that motivates individuals to achieve goals, learn new skills, and manage crises effectively.
What action should the nurse include in teaching Mr. Ross about skin care of the irradiated area?
- A. Applying ointment or lotion to the skin
- B. Washing the area with soap and water
- C. Keeping the area dry and open to air
- D. Massaging the area and exposing it to sunlight
Correct Answer: C
Rationale: Protecting the skin from irritation and moisture promotes healing.
When admitting a woman experiencing a spontaneous abortion at the ambulatory care center, the nurse notes that the admission form identifies the patient’s religion as Islam. What should the nurse understand about this patient?
- A. She should not receive any pork-derived products.
- B. She probably will not have purchased health insurance.
- C. Artificial contraception and abortion are prohibited.
- D. She will not be able to receive blood or blood products if an emergency develops.
Correct Answer: A
Rationale: Islamic dietary laws prohibit consumption of pork-derived products. While other options relate to Islamic beliefs, they are either incorrect assumptions or unrelated to immediate nursing care.
You are caring for a patient with Sophaged cancer. Which task could be delegated to the nursing assistant?
- A. Assist the patient with oral hygiene.
- B. Observe the patient's response to feedings.
- C. Facilitate expression of grief or anxiety.
- D. Initiate daily weights.
Correct Answer: A
Rationale: Oral hygiene is a basic care task that can be safely performed by a nursing assistant, while the other options require more advanced clinical judgment.