Nokea
The nurse is planning care for a client with severe postoperative pain. There is an order for 10 mg MSO4. Which of the following should the nurse do first?
- A. Obtain an intravenous infusion system.
- B. Prepare the medication for administration.
- C. Contact the Pharmacy Department.
- D. Contact the physician that ordered the medication.
Correct Answer: A
Rationale: MSO4 (morphine sulfate) is typically given IV for severe pain. Obtaining an IV infusion system ensures the medication can be administered safely and effectively.
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When the nurse enters the client's room, the nurse perceives that the client is staring straight ahead. Which of the following is the best course of action for the nurse to take next?
- A. Hold an interdisciplinary meeting on the client's behalf promptly.
- B. Consult with psychiatry.
- C. Listen to the client and observe the body language.
- D. Address the client by first name upon entering the room.
Correct Answer: C
Rationale: Listening to the client and observing body language allows the nurse to assess the client's condition and needs, considering macular degeneration may cause the client to appear to stare straight ahead due to central vision loss.
The nurse is caring for a client with a femoral fracture in traction. Which observation indicates a potential complication?
- A. Client reports mild discomfort.
- B. Traction ropes are aligned with the pulley.
- C. Foot is pale and cool to touch.
- D. Pin sites are clean and dry.
Correct Answer: C
Rationale: A pale, cool foot suggests impaired circulation, a serious complication requiring immediate attention.
A client has had multiple sclerosis (MS) for 15 years and has received various drug therapies. What is the primary reason why the nurse has found it difficult to evaluate the effectiveness of the drugs that the client has used?
- A. The client exhibits intolerance to many drugs.
- B. The client experiences spontaneous remissions from time to time.
- C. The client requires multiple drugs simultaneously.
- D. The client endures long periods of exacerbation before the illness responds to a particular drug.
Correct Answer: B
Rationale: Spontaneous remissions in MS make it challenging to attribute symptom improvement to drugs versus natural disease course. Intolerance, multiple drugs, or delayed responses are less primary factors.
A client will receive I.V. midazolam hydrochloride (Versed) during surgery. Which of the following should the nurse determine as a therapeutic effect?
- A. Amnesia.
- B. Nausea.
- C. Mild agitation.
- D. Blurred vision.
Correct Answer: A
Rationale: Midazolam's primary therapeutic effect is amnesia, reducing recall of surgical events. Nausea, agitation, and blurred vision are potential side effects, not desired outcomes.
Following a thoracotomy, the client has severe pain. Which of the following strategies for pain management will be most effective for this client?
- A. Repositioning the client immediately after administering pain medication.
- B. Reassessing the client 30 minutes after administering pain medication.
- C. Verbally reassuring the client after administering pain medication.
- D. Readjusting the pain medication dosage as needed according to the client's condition.
Correct Answer: D
Rationale: Readjusting pain medication dosage based on the client's condition ensures adequate pain control, critical for recovery. Repositioning, reassessing, and reassurance are supportive but less effective alone.