Nokea
Which of the following findings is the best indication that morphine has been effective?
- A. The client's vital signs are within normal limits
- B. The client has not requested additional medication
- C. The client is sitting comfortably with eyes closed
- D. The client rates pain as 3 on a scale from 0 to 10
Correct Answer: D
Rationale: The correct answer is D because the client rating pain as 3 on a scale from 0 to 10 indicates that the morphine has effectively reduced their pain. This is a direct measure of the drug's efficacy. Choice A is not a specific indicator of pain relief. Choice B could mean the client is tolerating the pain, not necessarily that the medication is effective. Choice C is subjective and doesn't provide concrete evidence of pain relief.
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Which of the following medications for pain relief can be taken concurrently with enoxaparin?
- A. Ibuprofen
- B. Naproxen sodium
- C. Acetaminophen
- D. Aspirin
Correct Answer: C
Rationale: Correct Answer: C (Acetaminophen)
Rationale:
1. Acetaminophen is a non-steroidal anti-inflammatory drug (NSAID) that does not affect platelet function.
2. Enoxaparin is an anticoagulant that works by inhibiting blood clot formation.
3. Taking acetaminophen with enoxaparin does not increase the risk of bleeding.
4. Choices A, B, and D (Ibuprofen, Naproxen sodium, Aspirin) are NSAIDs that can increase the risk of bleeding when taken with enoxaparin.
A nurse is preparing to administer heparin subcutaneously to a client. Which of the following actions should the nurse plan to take?
- A. Administer the medication outside the 5 cm (2 in) radius of the umbilicus.
- B. Aspirate for blood return before injecting.
- C. Rub vigorously after the injection to promote absorption.
- D. Place a pressure dressing on the injection site to prevent bleeding.
Correct Answer: A
Rationale: The correct answer is A: Administer the medication outside the 5 cm (2 in) radius of the umbilicus. This is because injecting heparin near the umbilicus can lead to bruising or hematoma formation. Subcutaneous injections are generally given in the fatty tissue of the abdomen, but it is important to avoid the area around the umbilicus to prevent discomfort and complications. Aspiration for blood return (B) is not necessary for subcutaneous injections as they are not typically administered into a blood vessel. Rubbing vigorously after the injection (C) is not recommended as it can cause tissue damage. Placing a pressure dressing on the injection site (D) is also unnecessary for subcutaneous injections.
A nurse is assessing a client 1 hr after administering morphine for pain. The nurse should identify which of the following findings as the best indication that the morphine has been effective?
- A. The client's vital signs are within normal limits.
- B. The client has not requested additional medication.
- C. The client is resting comfortably with eyes closed.
- D. The client rates pain as 3 on a scale from 0 to 10.
Correct Answer: D
Rationale: Correct Answer: D. The client rates pain as 3 on a scale from 0 to 10.
Rationale: Pain assessment is subjective. The client's self-report of pain is the most reliable indicator of pain relief efficacy. A pain rating of 3 indicates that the pain has decreased from the initial level, suggesting that the morphine has been effective in managing the pain.
Summary of Other Choices:
A: The client's vital signs being within normal limits may not directly correlate with pain relief. Vital signs can be influenced by various factors other than pain relief.
B: The client not requesting additional medication does not necessarily indicate effective pain management as some individuals may hesitate to ask for more medication.
C: The client resting comfortably with eyes closed may indicate relaxation but does not specifically confirm pain relief.
E, F, G: No additional choices provided.
A nurse is teaching a client about cyclobenzaprinWhich of the following client statements should indicate to the nurse that the teaching about cyclobenzaprine was effective?
- A. I will have increased saliva production
- B. I will continue taking the medication until the rash disappears
- C. I will taper off the medication before discontinuing it
- D. I will report any urinary incontinence
Correct Answer: C
Rationale: Correct Answer: C. "I will taper off the medication before discontinuing it."
Rationale: Tapering off cyclobenzaprine is important to prevent withdrawal symptoms due to its muscle relaxant properties. Abruptly stopping the medication can lead to adverse effects. This statement indicates understanding of proper medication management.
Incorrect Choices:
A: Increased saliva production is not a common side effect of cyclobenzaprine.
B: Continuing the medication until the rash disappears is not relevant to cyclobenzaprine.
D: Reporting urinary incontinence is important but not specifically related to cyclobenzaprine teaching.
Which of the following actions of sucralfate should the nurse include in the teaching for a client who is to start a new prescription for sucralfate for peptic ulcer disease?
- A. Decreases stomach acid secretion
- B. Neutralizes acids in the stomach
- C. Forms a protective barrier over ulcers
- D. Treats ulcers by eradicating H. pylori
Correct Answer: C
Rationale: The correct answer is C: Forms a protective barrier over ulcers. Sucralfate works by forming a protective barrier over ulcers in the stomach and small intestine, providing a physical barrier to prevent further damage from stomach acid. This action helps promote healing of the ulcers. Choices A, B, and D are incorrect because sucralfate does not decrease stomach acid secretion, neutralize acids in the stomach, or treat ulcers by eradicating H. pylori bacteria. It is important for the nurse to educate the client on the mechanism of action of sucralfate to ensure understanding and adherence to the treatment plan.