Nokea
The nurse is caring for a client with cancer who is exhibiting signs and symptoms that death is near. The client's daughter says that she does not want her mother to receive morphine because it will hasten her death. What response by the nurse is most appropriate?
- A. We always give morphine to clients at the end-of-life stage.
- B. We can give oxygen instead of morphine to help with breathing and distress.
- C. Morphine will reduce anxiety and reduce the sensation of air hunger in your mother.
- D. We will wait until the very end to give the morphine and use nonpharmacologic measures instead.
Correct Answer: C
Rationale: Morphine alleviates air hunger and anxiety in end-of-life care, improving comfort without necessarily hastening death, addressing the daughter’s concerns therapeutically.
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A 5-year-old client with hyperthyroidism is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
- A. Bradycardia
- B. Decreased appetite
- C. Exophthalmos
- D. Weight gain
Correct Answer: C
Rationale: Exophthalmos (bulging eyes) is a common sign of hyperthyroidism due to thyroid hormone effects on orbital tissues.
The nurse is preparing to administer a feeding via a nasogastric tube. The nurse would perform which of the following before initiating the feeding?
- A. Assess for tube placement by aspirating stomach content
- B. Place the patient in a left-lying position
- C. Administer feeding with 50% Dextrose
- D. Ensure that the feeding solution has been warmed in a microwave for 2 minutes
Correct Answer: A
Rationale: Aspirating stomach content confirms nasogastric tube placement, preventing aspiration.
A 19-year-old male has been experiencing vomiting and diarrhea for 3 days due to food poisoning. The nurse expects a urine specific gravity of
- A. 0.850.
- B. 1.005.
- C. 1.020.
- D. 1.041.
Correct Answer: D
Rationale: Dehydration from vomiting and diarrhea increases urine specific gravity (normal 1.005-1.030). 1.041 indicates concentrated urine due to fluid loss.
The doctor has ordered a Transcutaneous Electrical Nerve Stimulation (TENS) unit for the client with chronic back pain. The nurse teaching the client with a TENS unit should tell the client:
- A. You may be electrocuted if you use water with this unit.'
- B. Please report skin irritation to the doctor.'
- C. The unit may be used anywhere on the body without fear of adverse reactions.'
- D. A cream should be applied to the skin before applying the unit.'
Correct Answer: B
Rationale: Skin irritation is a common side effect of TENS; reporting it ensures timely management.
The nurse is caring for a client who is postoperative day 1 following a total hip replacement. Which of the following positions should the nurse AVOID placing the client in?
- A. Supine with legs abducted.
- B. High Fowler’s with legs extended.
- C. Side-lying on the unaffected side.
- D. Prone with legs adducted.
Correct Answer: D
Rationale: prone position with legs adducted can cause hip dislocation; abduction is maintained post-hip replacement