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The nurse cares for a client receiving fentanyl via patient-controlled analgesia (PCA). After the client reports increased pain, the nurse obtains a provider's order to adjust the PCA settings. While making the prescribed changes on the PCA device, the nurse should prioritize
- A. verifying the settings with a second nurse.
- B. educating the client about the medication's side effects.
- C. repositioning the client for nonpharmacological pain relief.
- D. reassessing the client's current pain level.
Correct Answer: A
Rationale: Verifying PCA settings with a second nurse ensures accuracy and safety.
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The nurse teaches a client who had cystoscopy about the urge to void when the procedure is over. What other teaching should be included?
- A. Ignore the urge to void.
- B. Force fluids.
- C. Ask for the bedpan.
- D. Ring for assistance to the bathroom.
Correct Answer: D
Rationale: After cystoscopy, the client may feel an urge to void due to bladder irritation. Teaching to ring for assistance ensures safety, as ambulation may be unsteady post-procedure.
A client had a colectomy 8½ hours ago. She has received 1,500 mL of dextrose 5% in water with normal saline solution. The client has just used a patient-controlled analgesia pump to administer morphine for pain, has been repositioned for comfort, and has stable pulse rate, respirations, and blood pressure. What should the nurse do next?
- A. Check that the family is comfortable.
- B. Assess vital signs following the use of morphine.
- C. Dim the lights in the room.
- D. Increase nasal oxygen from 2 to 3 L.
Correct Answer: B
Rationale: Morphine can cause respiratory depression or hypotension. Assessing vital signs after PCA use ensures the client's safety and detects adverse effects promptly.
The nurse is teaching a client about risk factors associated with atherosclerosis and how to reduce the risk. Which of the following is a risk factor that the client is not able to modify?
- A. Diabetes
- B. Age
- C. Exercise level
- D. Dietary preferences
Correct Answer: B
Rationale: Age is a non-modifiable risk factor for atherosclerosis, as the risk increases with advancing age due to cumulative vascular changes. Diabetes, exercise level, and dietary preferences can be managed or modified to reduce risk, making age the correct answer.
When the nurse talks with a client with multiple sclerosis who has slurred speech, which nursing intervention is contraindicated?
- A. Encouraging the client to speak slowly.
- B. Allowing extra time for the client to respond.
- C. Asking the client to repeat indistinguishable words.
- D. Asking the client to speak louder when tired.
Correct Answer: D
Rationale: Asking the client to speak louder when tired is contraindicated, as it may exacerbate fatigue and worsen speech. Encouraging slow speech, allowing time, and repeating words support communication.
The nurse in the infusion center is caring for a 27-year-old male.
Item 1 of 1
• Nurses' Notes
1401: Orders received for PRBC transfusion. 20-gauge peripheral vascular access device (VAD) started right antecubital space. Blood return was observed, and was flushed with 10 mL of sodium chloride (normal saline) without resistance. The client denied any discomfort at the VAD. Sterile dressing was applied to the VAD. The client was provided verbal education regarding the potential blood transfusion reactions. The client verbalized understanding.
1430: PRBC unit retrieved from blood bank. Vital signs were obtained prior to starting blood transfusion: 99.0° F (37.2° C) P 78, RR 18, BP 130/86, pulse oximetry reading 97% on room air.
1439: Verified and checked client ID and blood product with another RN. Initiated PRBC transfusion via y-type tubing. Will remain with the client for 15 minutes to observe for any potential transfusion-related reaction.
1454: The client denied any manifestations of a transfusion reaction. Vital signs: 99.5°F (37.5°C) P 75, RR 18, BP 132/85, pulse oximetry reading 96% on room air. Increased rate of PRBC transfusion.
1520: The client alerted RN to come to their bedside, reporting pain and discomfort at their VAD. VAD was swollen and cool to the touch.
• Orders
• Infuse 1 unit of packed red blood cells
• Medical History
• Sickle cell anemia
• Depression
The nurse reviews the clinical data and prepares to take action following the 1520 nursing note entry. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition and 2 parameters the nurse should monitor to assess the client's progress.
- A. pause the transfusion and discontinue the vascular access device,discontinue the packed red blood cell transfusion and return it to the blood bank
,start a new 20-gauge vascular access device in the opposite extremity,pause the transfusion obtain an order for acetaminophen - B. febrile transfusion reaction,infiltration at the vascular access device
hemolytic transfusion reaction,circulatory overload - C. discomfort and swelling at vascular access site,hemoglobin and hematocrit,temperature,blood pressure
Correct Answer:
Rationale: The nurse should monitor the discomfort and swelling at the VAD site. Pausing the transfusion, elevating the extremity, and applying a compress should alleviate the discomfort and swelling.
The nurse will need to monitor the client's hemoglobin and hematocrit to determine the efficacy of the PRBC transfusion. Generally, one unit of PRBCs will raise the hemoglobin by 1 g/dL.
It is inappropriate for the nurse to monitor the client's temperature as it pertains to infiltration. The client's temperature is not relevant in managing infiltration.
The blood pressure does not require monitoring because it does not show evidence of circulatory overload.