A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?

"I gave my client a bolus dose of morphine when I initiated the PCA pump."

"I noted that my client pushed the PCA button six times in the last hour, and the PCA lockout is set for 10 minutes."

"I told the client's family that they must not push the PCA button for the client."

"I discarded the remaining 2 milligrams of morphine from the PCA pump. Please document that you witnessed it."

Answer and Explanation

The Correct Answer is D

A. Administering a bolus dose of morphine at PCA initiation is a common practice.
B. Monitoring the frequency of button presses and understanding the lockout period is appropriate.
C. Educating the family not to push the PCA button is correct and ensures patient safety.
D. Discarding the remaining medication should be witnessed and documented correctly, but the process should follow the institution’s protocol, and witnessing should have been done before discarding, not after.

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Correct Answer is A

Explanation

A. Chlordiazepoxide can have teratogenic effects, so it is important to notify the provider if pregnancy is desired or suspected.
B. Doubling the dose can lead to overdose and severe side effects; medication should be taken exactly as prescribed.
C. Breast tenderness is not a known side effect of chlordiazepoxide.
D. Chlordiazepoxide can cause hypotension, not increased blood pressure.

A. “Vomiting is an indication of toxicity." B. “Increased flatulence is an indication of toxicity." C. “I will call my provider if experience any headaches." D. “I will report any loss of appetite."

Correct Answer is A

Explanation

A. Vomiting is a common early sign of lithium toxicity and indicates the need for immediate medical evaluation.
B. Increased flatulence is not a recognized symptom of lithium toxicity.
C. While headaches can be a side effect, they are not a specific indicator of lithium toxicity.
D. Loss of appetite can be a symptom of many conditions and is not a specific sign of lithium toxicity.

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A charge nurse is supervising a newly licensed nurse provide care for a client who has a PCA pump. Which of the following statements made by the nurse requires further action by the charge nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a female client who is experiencing alcohol withdrawal about chlordiazepoxide. Which of the following information should the nurse include in the teaching?

Correct Answer is A

Explanation

A nurse is teaching a client who has bipolar disorder and a prescription for lithium to recognize the manifestations of toxicity. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is A

Explanation

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