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The nurse administers the prescribed dose of hydromorphone 2 mg to a client who had knee replacement surgery 2 days ago. Which assessment finding is most concerning to the nurse?
- A. Client falls asleep while talking to the nurse
- B. Client has had no bowel movement for 2 days
- C. Client has one episode of nonbilious emesis
- D. Client reports experiencing pruritus
Correct Answer: A
Rationale: Falling asleep mid-conversation (A) may indicate opioid-induced respiratory depression, a life-threatening concern. Constipation (B), emesis (C), and pruritus (D) are less urgent side effects.
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The practical nurse is collaborating with the registered nurse to form a care plan for a client with a possible diagnosis of Guillain-Barré syndrome. The nurse should give priority to which client assessment?
- A. Orthostatic blood pressure changes
- B. Presence or absence of knee reflexes
- C. Pupil size and reaction to light
- D. Rate and depth of respirations
Correct Answer: D
Rationale: Respiratory assessment (D) is the priority in Guillain-Barré syndrome due to the risk of respiratory muscle paralysis. Reflexes (B) are relevant but less urgent, and blood pressure (A) and pupils (C) are not primary concerns.
The nurse is caring for a client with leukemia who is receiving the drug doxorubicin (Adriamycin). Which, if occurred, would be reported to the charge nurse immediately due to the toxic effects of this drug?
- A. Rales and distended neck veins
- B. Red discoloration of the urine and an output of 75 ml the previous hour
- C. Nausea and vomiting
- D. Elevated BUN and dry flaky skin
Correct Answer: A
Rationale: This drug can cause cardiotoxicity exhibited by changes in the ECG and congestive heart failure. Rales and distended neck veins are clinical manifestations of congestive heart failure, so answer A is correct. A reddish discoloration to the urine is a harmless side effect, so answer B is incorrect. An elevated BUN and dry, flaky skin are not specific to this drug, so answers C and D are incorrect.
The nurse is caring for a client who has a prescription for ampicillin 1.5 g IV in 100 mL of 0.9% sodium chloride to be administered over 30 minutes. The nurse has tubing with a drop factor of 15 available. How many gtts/min should the client receive? Record your answer using a whole number.
Correct Answer: 50
Rationale: Flow rate = (100 mL / 30 min) x (15 gtts/mL) = 50 gtts/min (A).
The nurse is reviewing discharge teaching for a client who had surgical repair of a retinal detachment. Which of the following instructions are appropriate for the nurse to include in the teaching? Select all that apply.
- A. Avoid rubbing or scratching the affected eye
- B. Avoid straining when having a bowel movement
- C. Expect occasional flashes of light during recovery
- D. Report any sudden pain to the health care provider
- E. Rest the eyes by refraining from reading and writing
Correct Answer: A, B, D
Rationale: Avoiding rubbing (A), straining (B), and reporting sudden pain (D) prevent complications. Flashes (C) are not expected and require reporting, and eye rest (E) is unnecessary unless specified.
Which of the following clients does the nurse identify as being at high risk for developing colorectal cancer? Select all that apply.
- A. Client who has a diet high in red meat and low in fiber
- B. Client who is morbidly obese
- C. Client with a 15-year history of ulcerative colitis
- D. Client with a 40-year history of cigarette smoking
- E. Client with a family history of colorectal cancer
Correct Answer: A, C, E
Rationale: High red meat/low fiber diet (A), ulcerative colitis (C), and family history (E) are established risk factors for colorectal cancer. Obesity (B) and smoking (D) have weaker associations.