Question

A nurse is assessing a client 1 5 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Answer 1

Correct Answers:

Respiratory rate of 8/min.

Rationale :

💁‍♂️A respiratory rate of 8/min indicates respiratory depression, a serious and potentially life-threatening adverse effect of IV morphine.

⚠️This occurs due to morphine’s action on the medulla oblongata, which can suppress the respiratory center.

📉Early detection is essential to prevent hypoventilation and possible hypoxia.

❌Being sleepy or having pain is expected; a low respiratory rate is the critical finding requiring immediate attention.

📌Core Message

Respiratory depression is a major adverse effect of IV opioid administration.

Answer 2

Correct Answers:

Have you had a recent influenza infection?

Rationale :

🦠Guillain-Barré Syndrome (GBS) often follows a viral or bacterial infection, particularly influenza or Campylobacter jejuni.

🔬The condition is thought to be autoimmune, where the body’s immune response to the virus mistakenly attacks peripheral nerves.

🧾Asking about recent illness helps confirm the clinical history and supports diagnosis.

❌Multivitamin use, travel, or alcohol history are unrelated to GBS development.

📌Core Message

A recent viral infection often precedes Guillain-Barré Syndrome.

Answer 3

Correct Answers:

MRI of the chest

Rationale :

💥Clients with permanent pacemakers should not undergo MRI unless the device is MRI-compatible due to risk of magnetic interference.

⚠️MRI can cause device malfunction, leading to loss of pacing or patient harm.

📋This test must be reviewed and clarified before proceeding to protect client safety.

✅Other orders like labs or dietary restrictions are not contraindicated.

📌Core Message

MRI is contraindicated in clients with non-MRI-compatible pacemakers.

Answer 4

Correct Answers:

Hemorrhage

Rationale :

🩸Following a TURP, the greatest risk is hemorrhage due to the highly vascular nature of the prostate gland.

⚠️Bleeding can occur suddenly and lead to hypovolemic shock if not detected early.

🧪Frequent assessments of urine output and color help identify bleeding complications.

❌Pain, infection, and retention are concerns but not as immediately life-threatening.

📌Core Message

Hemorrhage is the priority complication after TURP surgery.

Answer 5

Correct Answers:

"They are going to examine my gallbladder and ducts."

Rationale :

📸An oral cholangiogram is a radiographic study that uses contrast dye to visualize the gallbladder and bile ducts.

💊The dye is taken orally and helps identify blockages or stones in the biliary system.

❌It does not involve endoscopy, shock waves, or direct stone dissolution.

🧠Understanding the purpose ensures client cooperation and appropriate preparation.

📌Core Message

An oral cholangiogram evaluates gallbladder and ductal anatomy via contrast imaging.

Answer 6

Correct Answers:

A firm nodule with a hard crust.

Rationale :

🔬Squamous cell carcinoma presents as a firm, raised lesion with a scaly or crusted surface, often on sun-exposed skin.

🧴It may ulcerate or bleed and requires prompt dermatologic evaluation.

❌Purple nodules suggest Kaposi sarcoma; macules with scaling and tongue patches suggest other pathologies.

👁️Recognizing early signs supports early diagnosis and treatment.

📌Core Message

Squamous cell carcinoma appears as a firm, crusted nodule on the skin.

Answer 7

Correct Answers:

Hyperkalemia

Rationale :

🧪In prerenal acute kidney injury, the kidneys are unable to effectively excrete potassium, resulting in hyperkalemia.

⚠️This imbalance can cause serious cardiac dysrhythmias, making it a critical finding.

📉Sodium may be normal or low, and phosphorus and calcium levels vary based on severity.

📊Serum electrolytes must be monitored closely in AKI for complication prevention.

📌Core Message

Hyperkalemia is a serious electrolyte imbalance in prerenal AKI.

Answer 8

Correct Answers:

Poor impulse control.

Rationale :

🧠A stroke in the right cerebral hemisphere often results in impaired judgment, impulsivity, and lack of awareness of deficits.

🧭It affects behavioral and perceptual functions, not just motor coordination.

❌Language deficits and word discrimination are typically associated with left hemisphere strokes.

🧩Assessment should include evaluation of safety risk behaviors.

📌Core Message

Right hemisphere strokes cause impulse control issues and behavioral deficits.

Answer 9

Correct Answers:

Respiratory Alkalosis, Uncompensated.

Rationale :

🧪ABG: pH 7.6 (alkalosis), PaCO₂ 31 mmHg (↓), HCO₃ 25 mmol/L (normal) indicates respiratory alkalosis with no compensation.

💨The patient is hyperventilating, likely due to pain or anxiety, which lowers CO₂ levels excessively.

📉The kidneys have not yet adjusted bicarbonate, confirming uncompensated status.

🧠Symptoms like cramps, paresthesia, and tingling are classic signs of alkalosis.

📌Core Message

Hyperventilation causes uncompensated respiratory alkalosis.

Answer 10

Correct Answers:

Drink 2 liters ot fluid each day while taking the medication.

Rationale :

💧Allopurinol is prescribed to reduce uric acid levels in clients with gout, and adequate hydration helps prevent renal stone formation.

🧪Maintaining a fluid intake of at least 2 liters/day aids in excreting uric acid and decreases crystallization.

❌Aspirin should be avoided as it may alter uric acid excretion, worsening symptoms.

🥣The medication may be taken with food to minimize GI upset; crushing is not generally recommended unless approved.

📌Core Message

Adequate hydration prevents renal complications during allopurinol therapy.

1 :
A nurse is assessing a client 1 5 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

2 :
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barre syndrome (GBS). Which of the following questions should the nurse ask the client?

3 :
A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

4 :
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following complications is the priority for the nurse to monitor?

5 :
A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse an understanding of the procedure?

6 :
A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

7 :
A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

8 :
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

10 :
A nurse is teaching a client who has a new prescription for allopurinol for the treatment of gout. Which of the following instructions should the nurse include?

1 : A nurse is assessing a client 1 5 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

2 : A nurse is assessing a client who has a suspected diagnosis of Guillain-Barre syndrome (GBS). Which of the following questions should the nurse ask the client?

3 : A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

4 : A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following complications is the priority for the nurse to monitor?

5 : A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse an understanding of the procedure?

6 : A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

7 : A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

8 : A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

10 : A nurse is teaching a client who has a new prescription for allopurinol for the treatment of gout. Which of the following instructions should the nurse include?

1 :
A nurse is assessing a client 1 5 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

2 :
A nurse is assessing a client who has a suspected diagnosis of Guillain-Barre syndrome (GBS). Which of the following questions should the nurse ask the client?

3 :
A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

4 :
A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following complications is the priority for the nurse to monitor?

5 :
A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse an understanding of the procedure?

6 :
A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

7 :
A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

8 :
A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

10 :
A nurse is teaching a client who has a new prescription for allopurinol for the treatment of gout. Which of the following instructions should the nurse include?