Nokea
The client has just been given an IV dose of morphine 6 mg for neuropathic pain. A few minutes later, the nurse notes that the client's respirations are now 8, and his blood pressure has dropped from 122/83 mmHg to 88/67 mmHg. Which nursing action is the most appropriate?
- A. Prepare for intubation.
- B. Prepare to administer a dopamine infusion.
- C. Administer naloxone.
- D. Start an IV infusion of normal saline.
Correct Answer: C
Rationale: Respiratory depression (RR 8) and hypotension post-morphine (C) indicate opioid overdose, requiring naloxone to reverse effects, per ACLS guidelines. Intubation (A), dopamine (B), and saline (D) are secondary or inappropriate without reversal.
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The nurse is triaging a client involved in a chemical spill at a local chemical plant. The nurse assesses the client as responsive but unable to walk, with a respiratory rate of 28 and capillary refill <2 seconds. It would be correct for the nurse to triage this client with a
- A. yellow tag.
- B. red tag.
- C. black tag.
- D. green tag.
Correct Answer: A
Rationale: A yellow tag (A) is appropriate for a responsive client unable to walk with stable vital signs (RR 28, capillary refill <2 sec), indicating urgent but not immediate life-threatening needs. Red (B) is for critical, black (C) for deceased, and green (D) for minor injuries.
Which statement about the placebo is the most accurate?
- A. Placebos are often used to determine if the client's reports of pain are valid.
- B. Placebos are not used in research because the client has not given consent.
- C. Placebo use is unethical unless they are used in research with the subject's consent.
- D. Placebo use is illegal according to all states and the federal government.
Correct Answer: C
Rationale: Placebo use is ethical in research with informed consent (C), as it ensures transparency. Using placebos to validate pain (A) is unethical, placebos are used in research (B), and they are not illegal (D).
An advantage of mutual pretense at the end of life for the client is that it allows the client:
- A. To fully employ the ego defense mechanism of denial at the end of life.
- B. To exercise control over loved ones when they are at the end of life.
- C. To fully employ the ego defense mechanism of projection at the end of life.
- D. To preserve a degree of dignity and privacy at the end of life.
Correct Answer: D
Rationale: Mutual pretense allows clients to preserve dignity and privacy (D) by avoiding open acknowledgment of death, maintaining emotional comfort. Denial (A) and projection (C) are not the primary mechanisms, and control over loved ones (B) is not the focus.
The nurse cares for an unconscious client with a dissecting aortic aneurysm that needs urgent surgery. The client's family cannot be tracked. The nurse's priority action is:
- A. Send the client to surgery.
- B. Call the hospital lawyer.
- C. Search for all the client's contacts who can provide informed consent.
- D. Notify the nursing supervisor on-call and request their permission to waive informed consent.
Correct Answer: A
Rationale: For a life-threatening dissecting aortic aneurysm requiring urgent surgery, sending the client to surgery (A) is the priority under implied consent, as delay could be fatal. Contacting a lawyer (B), searching for contacts (C), or notifying the supervisor (D) delays critical intervention.
A client with a terminal illness asks the nurse about their prognosis. The nurse discusses the prognosis with the client, which the physician had previously divulged. Which ethical principle is the nurse demonstrating?
- A. Fidelity
- B. Confidentiality
- C. Beneficence
- D. Veracity
Correct Answer: D
Rationale: Discussing the prognosis truthfully (D) demonstrates veracity, the ethical principle of truth-telling. Fidelity (A) is keeping promises, confidentiality (B) protects information, and beneficence (C) promotes well-being, but veracity is most relevant here.