A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Emesis of 250 mL

Increased respiratory rate to 26/min

Decreased anxiety

Decreased urinary output

Answer and Explanation

The Correct Answer is C

C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.

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Correct Answer is B

Explanation

Telmisartan is an angiotensin II receptor blocker (ARB) used to treat hypertension by lowering blood pressure. Therefore, a decrease in blood pressure would suggest that the medication is working as intended.

Telmisartan has no effect on respiratory rate, urine output or blood glucose.

A. Wash hands with alcohol-based hand rub. B. Clean surfaces with chlorhexidine. C. Obtain a stool specimen with gloves. D. Place the client in a protective environment.

Correct Answer is C

Explanation

C. When collecting a stool specimen from a client with Clostridium difficile infection, the nurse should wear gloves to prevent the spread of the bacteria to themselves and other patients. Proper hand hygiene should also be performed after glove removal.
A. While alcohol-based hand rubs are effective against many types of bacteria and viruses, they are not effective against Clostridium difficile spores. Handwashing with soap and water is recommended for hand hygiene in cases of Clostridium difficile infection, as it is more effective at removing spores from the hands.
B. Chlorhexidine is a disinfectant commonly used for skin antisepsis, but it is not effective against
D. Placing the client in a protective environment is not typically necessary for clients with Clostridium difficile gastroenteritis unless they are immunocompromised or have other conditions that require protective isolation.

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A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is taking telmisartan. The nurse should identify that which of the following findings indicates that the medication has been effective?

Correct Answer is B

Explanation

A nurse is planning care for a client who has Clostridium difficile gastroenteritis. Which of the following is an appropriate nursing action?

Correct Answer is C

Explanation

A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?

A nurse is caring for a client who has gastroenteritis. Which of the following assessment findings should the nurse recognize as an indication that the client is experiencing dehydration?

A nurse is caring for a client who requires protective isolation following a hematopoietic stem cell transplant. Which of the following interventions should the nurse implement to protect the client from infection?

A nurse is planning care for a client who has developed nephrotic syndrome. Which of the following dietary recommendations should the nurse include?

A nurse working in an outpatient clinic is planning a community education program about reproductive cancers. The nurse should identify which of the following manifestations as a possible indication of cervical cancer?