A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse's priority?

Respiratory rate 7/min

Distended bladder

Last bowel movement was 3 days ago

Reports pain of 8 on a scale from 0 to 10

Answer and Explanation

The Correct Answer is A

A.   A respiratory rate of 7/min is below the normal range and may indicate opioid- induced respiratory depression, which is a life-threatening complication requiring immediate intervention.
B.   While important, a distended bladder does not pose an immediate threat to the client's life compared to respiratory depression.
C.   Constipation is a common side effect of opioid medications but does not require immediate intervention unless accompanied by severe symptoms such as fecal impaction or bowel obstruction.
D.   Pain management is important, but respiratory depression takes priority as it can lead to respiratory arrest and death.

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Correct Answer is ["A","B","D"]

Explanation

A. The nurse's signature confirms that the client signed the informed consent document in the nurse's presence, verifying that the client provided consent voluntarily.
B. The nurse's signature confirms that the client has legal capacity and authority to provide consent for the proposed treatment or procedure.
C. The nurse's signature does not confirm the absence of a mental health condition; rather, it confirms that the client has provided informed consent.

D. The nurse's signature confirms that the client provided consent voluntarily and was not coerced or unduly influenced to do so.
E. While it is important for the client to understand the information provided, the nurse's signature does not specifically confirm this requirement.

A. "Use povidone-iodine to clean around the stoma." B. "Cut the opening of the pouch / of an inch larger than the stoma." C. "Empty the ostomy pouch when it becomes one-third full of contents." D. "Place a piece of gauze over the stoma while changing the pouch." E. "Expect the stoma to turn a purple-blue color as it heals."

Correct Answer is ["B","C","D"]

Explanation

A. Povidone-iodine is not recommended for cleaning around the stoma as it may cause irritation.
B. Ensuring the pouch opening is slightly larger than the stoma helps prevent irritation and ensures proper fit.
C. Regular emptying of the ostomy pouch prevents leakage and skin irritation. It also prevents it from becoming too heavy and pulling away from the skin.
D. The nurse should advise the client to place a piece of gauze over the stoma while changing the pouch to protect it from injury and contamination.
E. A purplish-blue change in the stoma is an indication of impaired blood supply to the stoma and should be promptly reported to the healthcare provider.

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A nurse is assessing a client who received morphine for severe pain 30 min ago. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A staff nurse is teaching a newly hired nurse how to complete an informed consent document for a client. The staff nurse should include that the nurse's signature on the form confirms which of the following requirements? (Select all that apply)

Correct Answer is ["A","B","D"]

Explanation

A nurse is completing discharge teaching about ostomy care with a client who has a new stoma. Which of the following instructions should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["B","C","D"]

Explanation

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