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 A

Explanation

Choice A rationale:

Unclamping the client's gastrostomy tube before connecting the syringe is the correct action. This allows the feeding to flow freely into the stomach. Clamping the tube while administering the feeding would prevent the formula from entering the stomach properly.

Choice B rationale:

Verifying the client's gastric pH to be at least 7 prior to feeding is not necessary for administering intermittent enteral feedings. Gastric pH varies widely among individuals and is not a standard requirement before every feeding.

Choice C rationale:

Pouring the client's formula into the syringe and adjusting the syringe's height to control the rate of flow is not recommended. Controlling the rate of flow in this manner is imprecise and can lead to inconsistent delivery of the formula, potentially causing discomfort or complications.

Choice D rationale:

Applying sterile gloves before accessing the client's gastrostomy tube is an important step in infection control, but it is not specifically related to administering intermittent enteral feedings. Sterile gloves are essential to prevent contamination and infection during tube maintenance and insertion, not during the feeding process itself.

A. Verifying placement of a nasogastric tube. B. Evaluating a client's understanding of how to use crutches. C. Replacing the gauze on a skin abrasion. D. Monitoring bowel sounds.

Correct Answer is C

Explanation

Choice A rationale:

Verifying placement of a nasogastric tube requires specialized training and knowledge to ensure correct placement and prevent complications. The nurse should retain this task to ensure patient safety.

Choice B rationale:

Evaluating a client's understanding of how to use crutches involves assessing the client's comprehension and ability to use crutches safely and effectively. This task requires nursing judgment and should not be delegated to an assistive personnel.

Choice C rationale:

Replacing the gauze on a skin abrasion is a task that can be safely assigned to an assistive personnel. It involves basic wound care, which typically falls within the scope of practice for assistive personnel. The AP can be trained to follow established protocols for wound cleaning and dressing changes.

Choice D rationale:

Monitoring bowel sounds requires clinical judgment and the ability to recognize variations from the normal range. The nurse should perform this task, as it involves assessing the client's condition and making appropriate decisions based on the findings.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is receiving intermittent enteral feedings via a gastrostomy tube. Which of the following actions should the nurse take when administering the feeding?

Correct Answer is A

Explanation

A nurse is preparing to assign tasks to an assistive personnel (AP). Which of the following tasks should the nurse assign to the AP?

Correct Answer is C

Explanation

A nurse is planning care for a client who reports having difficulty sleeping. Which of the following interventions should the nurse include in the plan of care?

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?

A nurse is completing a preadmission interview for a client who is to undergo surgery the following day. The client reports a latex allergy. Which of the following interventions should the nurse include when planning care for the client's surgery? (Select all that apply)

A nurse is caring for a client who has a temperature of 40°C (104°F). Which of the following interventions should the nurse take?

A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?

A nurse on a medical-surgical unit is planning care for four clients. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

A nurse is assessing a client's coping skills. Which of the following should the nurse identify as an internal stressor?