A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Tachycardia

Lacrimation

Hypertension

Urinary retention

Answer and Explanation

The Correct Answer is D

The correct answer is D. Urinary retention. Morphine is an opioid analgesic that can cause urinary retention by inhibiting bladder contractions and increasing sphincter tone. Urinary retention can lead to urinary tract infections, bladder distension, and renal impairment if not treated.

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Correct Answer is D

Explanation

A.Taping the tube to the child's cheek is not a recommended practice. It can cause skin irritation, discomfort, or even accidental removal of the tube. Proper securing of the tube to the abdomen using appropriate devices is the preferred method to prevent dislodgement.

B.Applying water-soluble lubricant to the gastrostomy site routinely is not recommended because it can trap moisture, leading to maceration or infection.

C.Some gastrostomy tubes require an extension set for feeding, especially low-profile devices (e.g., button-type gastrostomy tubes). This extension makes it easier to administer feeds or medications and can be removed afterward. However, this is not typically part of routine site care.

D.Securing the tubing to the child's abdomen helps prevent accidental dislodgement or pulling of the gastrostomy tube. This can be done using appropriate securing devices, such as adhesive dressings or commercially available tube holders, as recommended by the healthcare provider.

A. Uses a firm-bristled toothbrush B. Increased intake of green, leafy vegetables C. Drinks 2,500 mL of fluid per day D. Wears a face mask around others E. None F. None

Correct Answer is A

Explanation

Pernicious anemia is caused by a deficiency of vitamin B12, which is essential for red blood cell production and neurological function. Clients with this condition often experience glossitis (inflammation of the tongue) and oral mucosal atrophy, making the oral tissues fragile and more prone to injury. Using a firm-bristled toothbrush can cause gum trauma, leading to bleeding, ulcers, and discomfort. A soft-bristled toothbrush is recommended to minimize the risk of injury.

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A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing site care for a child who has a gastrostomy enteral tube. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is collecting data from a client who has pernicious anemia. The nurse should identify that which of the following findings increases the client's risk for injury?

Correct Answer is A

Explanation

A nurse is collecting data from a child who has pertussis. Which of the following manifestations should the nurse expect?

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