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The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
- A. This must be a very difficult time for you.'
- B. You did nothing wrong.'
- C. With surgery, your baby should have a full recovery.'
- D. Is there any particular reason why you think this is your fault?'
Correct Answer: A
Rationale: Empathy supports emotional expression without judgment.
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The nurse is preparing a bladder irrigation for an adult client who has a long-term indwelling urinary catheter. The urine is cloudy with fibrin clots and sediment. Which intervention should the nurse implement?
- A. Power flush with 60 mL to remove mucous obstructions.
- B. Slowly irrigate catheter with saline using an infusion pump.
- C. Clamp the catheter for 30 minutes prior to irrigating.
- D. Use a sterile syringe to irrigate with 20 mL normal saline.
Correct Answer: B
Rationale: Slow irrigation safely clears clots and sediment.
The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?
- A. Morphine 2.0 mg IV every four hours for severe pain.
- B. Morphine 2 mg IV every 4 hr PRN for severe pain.
- C. IV MS 2 mg every 4 hr as needed for severe pain.
- D. IV MS 2.0 mg every 4 hours PRN for severe pain.
Correct Answer: B
Rationale: Full drug name and no trailing zeros ensure clarity.
A bedfast female client awakens during the night, reporting to the nurse that she is 'uncomfortable.' What action should the nurse implement first?
- A. Engage the client in relaxation exercises.
- B. Offer to sit with the client until she relaxes.
- C. Administer a prescribed PRN analgesic.
- D. Assist the client to a different position.
Correct Answer: D
Rationale: Repositioning often relieves discomfort.
A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?
- A. Ask the UAP to offer a backrub to the client.
- B. Reassess the client and the level of pain.
- C. Tell the client the medication needs more time to work.
- D. Encourage the client to focus on taking deep breaths.
Correct Answer: B
Rationale: Reassessing pain evaluates medication effectiveness.
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
- A. Notify the information services department of the situation.
- B. Print electronic medical record (EMR) from the backup server.
- C. Identify information as a late entry in the record.
- D. Wait for notification that the system has been rebooted.
Correct Answer: A
Rationale: IT notification resolves system issues quickly.