Nokea
The physician orders Morphine Sulfate 2-4 mg IV push every 2 hours prn pain for a client who has postoperative pain following abdominal surgery. Prior to performing an abdominal dressing change with packing at 10 AM, the nurse assesses the client's pain level as 1 on a scale of 0 = no pain to 10 = the worst pain. The client is awake and oriented and vital signs are within normal limits. The nurse reviews the pain medication record (see chart). The nurse should:
- A. Perform the dressing change.
- B. Administer Morphine 2 mg IV before the dressing change.
- C. Administer Morphine 4 mg IV after the dressing change.
- D. Call the physician for a new medication order.
Correct Answer: A
Rationale: With a pain level of 1, the client does not require morphine (prn order). Performing the dressing change is appropriate, as the pain is minimal and manageable.
You may also like to solve these questions
A client with a hemorrhagic stroke is slightly agitated, heart rate is 118, respirations are 22, bilateral rhonchi are auscultated, SpO2 is 94%, blood pressure is 144/88, and oral secretions are noted. What order of interventions should the nurse follow when suctioning the client to prevent increased intracranial pressure (ICP) and maintain adequate cerebral perfusion?
- A. Suction the airway.
- B. Hyperoxygenate.
- C. Suction the mouth.
- D. Provide sedation.
Correct Answer: B,D,A,C
Rationale: The correct order is: 1) Hyperoxygenate to prevent hypoxia (B); 2) Provide sedation to reduce agitation and ICP spikes (D); 3) Suction the airway to clear secretions (A); 4) Suction the mouth to remove residual secretions (C). This sequence minimizes ICP increases and ensures oxygenation.
A 68-year-old male has been receiving monthly doses of chemotherapy for treatment of stage III colon cancer. He comes to the clinic for his fourth monthly dose. Which laboratory result(s) should be reported to the oncologist before the next dose of chemotherapy is administered? Select all that apply.
- A. Hemoglobin of 14.5 g/dL.
- B. Platelet count of 40,000/mm³.
- C. Blood urea nitrogen (BUN) level of 12 mg/dL.
- D. White blood cell count of 2,300/mm³.
- E. Temperature of 101.2°F (38.4°C).
- F. Urine specific gravity of 1.020.
Correct Answer: B,D,E
Rationale: Low platelet count (B), low white blood cell count (D), and fever (E) indicate thrombocytopenia, neutropenia, and possible infection, respectively, which are contraindications for chemotherapy due to increased risk of bleeding and infection.
Which of the following explains the influence of aging on the development of peripheral vascular disease?
- A. Decreased resistance
- B. Increased resistance
- C. Decreased viscosity
- D. Increased viscosity
Correct Answer: B
Rationale: Aging increases vascular resistance due to arterial stiffening and reduced elasticity from collagen buildup and atherosclerosis. This elevates blood pressure and impairs peripheral blood flow, contributing to PVD. Resistance does not decrease, and viscosity changes are less significant in aging-related PVD.
A health care provider has just inserted nasal packing for a client with epistaxis. The client is taking ramipril (Altace) for hypertension. What should the nurse instruct the client to do?
- A. Use 81 mg of aspirin daily for relief of discomfort.
- B. Omit the next dose of ramipril (Altace).
- C. Remove the packing if there is difficulty swallowing.
- D. Avoid rigorous aerobic exercise.
Correct Answer: D
Rationale: Avoiding rigorous aerobic exercise prevents increased blood pressure, which could worsen epistaxis. Aspirin increases bleeding risk. Omitting ramipril is not indicated without physician guidance. Removing packing is unsafe and should be done by a healthcare provider.
A client with Cushing's disease tells the nurse that the physician said the morning serum cortisol level was within normal limits. The client asks, 'How can that be? I'm not imagining all these symptoms!' The nurse's response will be based on which of the following?
- A. Some clients are very sensitive to the effects of cortisol and develop symptoms even with normal levels.'
- B. A single random blood test cannot provide reliable information about endocrine levels.'
- C. The excessive cortisol levels seen in Cushing's disease commonly result from loss of the normal diurnal secretion pattern.'
- D. Tumors tend to secrete hormones irregularly, and the hormones are generally not present in the blood.'
Correct Answer: C
Rationale: Cushing's disease disrupts the normal diurnal cortisol rhythm, leading to consistently high levels, which may not be captured in a single morning test.