Nokea
The nurse is reviewing a care plan for a client with chronic pain receiving morphine sulfate. Which of the following aspects in the plan of care require revision?
- A. Adjust the physician's order based on the client's pain level
- B. Ensure naloxone is always available
- C. Check the client's blood pressure before administering morphine sulfate
- D. Provide a high-fiber diet
Correct Answer: A
Rationale: Nurses cannot adjust physician orders independently; this requires clarification or a new order from the provider.
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The nurse is preparing a community presentation on oral cancer. Which of the following is a primary risk factor for oral cancer that the nurse should include in the presentation?
- A. Use of alcohol.
- B. Frequent use of mouthwash.
- C. Lack of vitamin B12.
- D. Lack of regular teeth cleaning by a dentist.
Correct Answer: A
Rationale: Alcohol use is a well-established primary risk factor for oral cancer, often acting synergistically with tobacco use. Frequent mouthwash use, vitamin B12 deficiency, and lack of dental cleanings are not primary risk factors for oral cancer.
A male client with a head injury regains consciousness and the normal loss. Which of the following nursing statements is most appropriate as the client awakens?
- A. I'll get your family.
- B. Can you tell me your name and where you live?
- C. I'll bet you're a little confused right now.
- D. You are in the hospital. You were in an accident and unconscious.
Correct Answer: D
Rationale: Providing clear, concise orientation information is most appropriate for a client regaining consciousness to reduce confusion and anxiety. Calling family, asking for personal details, or assuming confusion may overwhelm or distress the client.
The nurse prepares to administer promethazine (Phenergan) 35 mg I.M. as ordered p.r.n. for a client with cholecystitis complaining of nausea. The ampule label reads that the medication is available in 25 mg/mL. How many milliliters should the nurse administer?
Correct Answer: 1.4 mL
Rationale: To calculate: 35 mg ÷ 25 mg/mL = 1.4 mL. Thus, the nurse should administer 1.4 mL of promethazine.
The client with Addison's disease should anticipate the need for increased glucocorticoid supplementation in which of the following situations:
- A. Returning to work after a weekend.
- B. Going on vacation.
- C. Having oral surgery.
- D. Having a routine medical checkup.
Correct Answer: C
Rationale: Oral surgery is a stressful event requiring increased glucocorticoid supplementation to prevent adrenal crisis.
A client weighs 300 lb (136 kg) and has a history of deep vein thrombosis and thrombophlebitis. When reviewing a teaching plan with this client, the nurse knows that the client has understood the nurse's instructions when he states he will:
- A. Avoid exercise
- B. Lose weight
- C. Perform leg lifts every 4 hours
- D. Wear support hose, using rubber bands to hold the stockings up
Correct Answer: B
Rationale: Weight loss reduces pressure on veins and improves circulation, critical for managing DVT and thrombophlebitis in an obese client. Avoiding exercise increases stasis, leg lifts are insufficient alone, and rubber bands can cause constriction, negating support hose benefits.