A nurse receives a telephone prescription from the provider, who states, "Four milligrams of morphine diluted with five milliliters of sterile water, intravenously each morning at nine o'clock before client dressing changes." Which of the following entries by the nurse indicates correct transcription of the prescription?

MSO4 4 mg IV bolus daily before dressing changes and dilute with 5 cc of water.

Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water.

Morphine 4 mg IV bolus Q.D. before dressing changes and dilute with 5 cc of sterile water.

MSO4 4 mg IV bolus daily @9 AM, dilute with 5 mL of sterile water.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

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Correct Answer is B

Explanation

Choice A rationale:

Moving the client using a slider board might be appropriate for transferring clients with relatively lower weight and mobility challenges. However, in this scenario, where the client weighs 136 kg (300 lb), a more advanced transfer method is necessary to ensure the safety of both the client and the healthcare providers.

Choice B rationale:

Using an air-assisted transfer device is suitable for transferring clients with higher weight, as it helps reduce friction and strain during the transfer process. This approach ensures a smoother transfer and minimizes the risk of injury to both the client and the assistive personnel.

Choice C rationale:

Raising the bed to 5 cm (2 in) above the level of the stretcher might not provide enough clearance for a safe transfer. Additionally, the use of assistive devices is more appropriate for transferring clients with significant weight, rather than relying solely on adjusting the bed height.

Choice D rationale:

Positioning the head of the bed at 25° prior to the transfer is not directly relevant to the process of transferring a client from a bed to a stretcher. The focus should be on using appropriate equipment and techniques for safe and efficient transfer, especially considering the client's weight.

A. Place a sterile kit on the overbed table above waist level. B. Open the outermost flap of the sterile kit toward their body. C. Turn their back to the sterile field when coughing during the procedure. D. Hold a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field.

Correct Answer is B

Explanation

Choice A rationale:

Placing a sterile kit on the overbed table above waist level is incorrect. Sterile fields need to be set up at or below waist level to ensure that they remain within the nurse's line of sight and control. This minimizes the risk of contamination and maintains the sterility of the field.

Choice B rationale:

Opening the outermost flap of the sterile kit toward their body is the correct action. This prevents air currents from blowing contaminants onto the sterile field, maintaining its sterility. Opening the flap away from the body could introduce potential contaminants onto the field, compromising its integrity.

Choice C rationale:

Turning their back to the sterile field when coughing during the procedure is incorrect. Proper aseptic technique involves turning away from the sterile field and coughing or sneezing into a tissue or elbow while maintaining a distance from the sterile area. This prevents the dispersal of microorganisms onto the field.

Choice D rationale:

Holding a package of sterile gauze 30.5 cm (12 in) above the sterile field when dropping the gauze onto the field is incorrect. The appropriate technique is to hold the gauze slightly above the sterile field to allow it to fall onto the field without direct contact. Holding it 12 inches above is unnecessary and might increase the risk of dropping it from too high, potentially contaminating the field. The height should be minimal to avoid unnecessary air currents.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to transfer a client who weighs 136 kg (300 lb) from a bed to a stretcher with the aid of an assistive personnel (AP). Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is setting up a sterile field prior to changing a client's dressing. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is admitting a client who has rubella. Which of the following actions should the nurse plan to take?

A nurse is caring for a group of clients. Which of the following client-care situations requires the nurse to complete an incident report?

A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

A nurse is planning teaching for a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions should the nurse take prior to performing the teaching?

A nurse is using a Doppler ultrasound stethoscope to assess the pedal pulses of a client who has peripheral vascular disease. Which of the following actions should the nurse plan to take?

A home health care nurse is conducting a fall risk assessment for a client who has osteoarthritis and lives alone. The nurse should identify that which of the following factors creates a risk for falls?

A nurse is teaching a client to manage stress by using progressive relaxation techniques. Which of the following statements by the client indicates an understanding of the teaching?

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?