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The nurse is caring for a postoperative client who reports a pain level of 8 out of 10. The client has an order for morphine 4 mg IV every 4 hours as needed. What is the nurse's priority action?
- A. Administer the morphine as ordered.
- B. Assess the client's vital signs and pain characteristics.
- C. Apply a warm compress to the surgical site.
- D. Encourage the client to use distraction techniques.
Correct Answer: B
Rationale: Assessing vital signs and pain characteristics ensures the pain is accurately evaluated and the morphine is safe to administer, considering potential side effects like respiratory depression.
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A client with a history of asthma is prescribed a metered-dose inhaler with albuterol. The nurse should teach the client to:
- A. Use the inhaler daily to prevent asthma attacks.
- B. Shake the inhaler well before each use.
- C. Hold the breath for 2 seconds after inhaling.
- D. Clean the inhaler with soap and water daily.
Correct Answer: B
Rationale: Shaking the inhaler well before use ensures proper mixing of the medication for effective delivery.
A male client has been diagnosed as having a low sperm count during infertility studies. After instructions by the nurse about some causes of low sperm counts, the nurse determines that the client needs further instructions when he says low sperm counts may be caused by which of the following?
- A. Varicocele.
- B. Frequent use of saunas.
- C. Endocrine imbalances.
- D. Decreased body temperature.
Correct Answer: D
Rationale: Decreased body temperature is not a cause of low sperm count; elevated temperatures, such as from saunas, can impair spermatogenesis, indicating a need for further teaching.
Which of the following medications should the nurse anticipate administering in the event of a heparin overdose?
- A. Warfarin sodium (Coumadin).
- B. Protamine sulfate.
- C. Acetylsalicylic acid (ASA).
- D. Atropine sulfate.
Correct Answer: B
Rationale: Protamine sulfate is the antidote for heparin overdose, neutralizing its anticoagulant effects.
The nurse is caring for a client in labor who has butorphanol tartrate prescribed for the relief of labor pain. During the administration of the medication, the nurse should ensure that which priority item is readily available?
- A. Naloxone
- B. Meperidine hydrochloride
- C. An intravenous form of an antiemetic
- D. An intravenous solution of normal saline
Correct Answer: A
Rationale: Butorphanol tartrate is an opioid analgesic that provides systemic pain relief during labor. The nurse should ensure that naloxone and resuscitation equipment are readily available to treat respiratory depression, should it occur. Meperidine hydrochloride is also an opioid analgesic that may be used for pain relief, but it also causes respiratory depression. Although an antiemetic may be prescribed for vomiting, antiemetics may enhance the respiratory depressant effects of the butorphanol tartrate. Although an IV access is desirable, the administration of normal saline is unrelated to the administration of this medication.
The nurse should tell a client who is scheduled for a bone marrow biopsy that the specimen can be withdrawn from which site?
- A. Ribs
- B. Femur
- C. Scapula
- D. Sternum
Correct Answer: D
Rationale: The most common sites for bone marrow biopsy in the adult are the iliac crest and the sternum. These areas are rich in bone marrow and are easily accessible for testing. The femur, scapula, and ribs are not sites for bone marrow biopsy.