Nokea
The nurse believes that a client who frequently requests pain medication may have a substance abuse problem. Which intervention reflects the nurse's value of client autonomy over veracity?
- A. Administer the prescribed analgesic when requested
- B. Enroll the client in a substance abuse program
- C. Collaborate with the healthcare provider to provide a placebo
- D. Document the frequency of medication requests
Correct Answer: A
Rationale: Administering the prescribed analgesic when requested reflects the nurse's value of client autonomy over veracity. This choice respects the client's right to manage their pain as they see fit. Enrolling the client in a substance abuse program (Choice B) assumes substance abuse without evidence and infringes on the client's autonomy. Providing a placebo (Choice C) violates the principle of beneficence and autonomy by deceiving the client. Documenting the frequency of medication requests (Choice D) is important for assessment but does not directly address the client's autonomy in managing their pain.
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A client who is bleeding after a vaginal delivery receives a prescription for methylergonovine (Methergine) 0.4 mg IM every 2 hours, not to exceed 5 doses. The medication is available in ampules containing 0.2 mg/ml. What is the maximum dosage in mg that the nurse should administer to this client?
- A. Encourage oral fluids as tolerated
- B. Decrease oral intake to 200 ml
- C. Allow the client to have exactly 400 ml oral intake
- D. Limit oral intake to 900 to 1,000 ml
Correct Answer: D
Rationale: The maximum dosage the nurse should administer is 2 mg. This is calculated based on the prescription of 0.4 mg IM every 2 hours, not to exceed 5 doses. Since the medication is available in ampules containing 0.2 mg/ml, the nurse should administer 2 ml (0.2 mg/ml x 10 ml) for each dose, not exceeding 5 doses. Therefore, the nurse should limit the client's oral intake to 900 to 1,000 ml, to avoid exceeding the maximum dosage of 2 mg.
A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?
- A. Decrease the oxygen flow rate
- B. Increase the oxygen flow rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct Answer: A
Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.
Several clients on a telemetry unit are scheduled for discharge in the morning, but a telemetry-monitored bed is needed immediately. The charge nurse should make arrangements to transfer which client to another medical unit?
- A. Learning to self-administer insulin injections after being diagnosed with diabetes mellitus
- B. Ambulatory following coronary artery bypass graft surgery performed six days ago
- C. Wearing a sling immobilizer following permanent pacemaker insertion earlier that day
- D. Experiencing syncopal episodes resulting from the dehydration caused by severe diarrhea
Correct Answer: A
Rationale: The correct answer is A because transferring a stable client who is learning self-care, such as self-administering insulin injections after being diagnosed with diabetes mellitus, provides the needed telemetry-monitored bed without compromising the client's care. Choice B should not be transferred as the client is ambulatory following surgery and does not require telemetry monitoring. Choice C should not be transferred as the client is wearing a sling immobilizer following pacemaker insertion, which requires close monitoring. Choice D should not be transferred as the client is experiencing syncopal episodes due to severe dehydration, necessitating telemetry monitoring for immediate intervention.
The nurse is assessing a client who has a prescription for digoxin (Lanoxin). Which finding indicates that the client is at risk for digoxin toxicity?
- A. Heart rate of 60 beats per minute
- B. Blood pressure of 120/80 mm Hg
- C. Respiratory rate of 18 breaths per minute
- D. Serum potassium level of 3.0 mEq/L
Correct Answer: D
Rationale: A low serum potassium level increases the risk of digoxin toxicity. Digoxin toxicity is more likely to occur in individuals with low potassium levels because potassium is crucial for proper heart function. A heart rate of 60 beats per minute, blood pressure of 120/80 mm Hg, and respiratory rate of 18 breaths per minute are within normal ranges and do not directly indicate an increased risk of digoxin toxicity.
The healthcare provider prescribes a diet high in vitamin C for a client with a leg wound. Which food should the nurse encourage the client to eat?
- A. Bananas and pineapple
- B. Cottage cheese and crackers
- C. Peanut butter and jelly
- D. Tomato and lettuce salad
Correct Answer: D
Rationale: Tomatoes and lettuce are high in vitamin C, making them suitable choices for a diet prescribed for wound healing. Bananas and pineapple (Choice A) are not particularly high in vitamin C compared to tomatoes and lettuce. Cottage cheese and crackers (Choice B) as well as peanut butter and jelly (Choice C) do not provide significant amounts of vitamin C, which is essential for wound healing.