The nurse working on a mental health unit is prioritizing nursing care activities because of a staffing shortage. One practical nurse (PN) is on the unit with the nurse, and another RN is expected to arrive within two hours. Clients need to be awakened and morning medications need to be prepared. Which plan is best for the nurse to implement?

Wake all the clients and instruct them to go to dining area for medication administration.

Allow the clients to sleep until a third staff person can assist with unit activities.

Explain to the clients that it will be necessary to cooperate until another RN arrives.

Ask the PN to administer medications as clients are awakened so both nurses are available.

Answer and Explanation

The Correct Answer is D

A. Wake all the clients and instruct them to go to dining area for medication administration: Waking all clients at once without adequate staffing may create safety risks and chaos, especially on a mental health unit where supervision is essential.

B. Allow the clients to sleep until a third staff person can assist with unit activities: Delaying medication administration could compromise timely treatment and therapeutic outcomes, making this an unsafe approach.

C. Explain to the clients that it will be necessary to cooperate until another RN arrives: While client communication is important, it does not address the immediate need for safe medication administration and supervision.

D. Ask the PN to administer medications as clients are awakened so both nurses are available: Delegating medication administration to the PN while clients are awakened in a staggered, controlled manner ensures timely delivery of medications, maintains client safety, and allows the nurse to supervise and manage the unit effectively during a staffing shortage.

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Correct Answer is C

Explanation

A. “When did these voices begin?”: While establishing the onset and history of auditory hallucinations is important for diagnosis and planning care, it does not immediately address the potential risk for harm or violence.

B. “Have you taken any hallucinogens?”: Substance use can contribute to hallucinations, but asking this first delays identifying an immediate safety risk posed by the command hallucinations.

C. “Are you planning to obey the voices?”: Command hallucinations telling someone to harm others represent a critical safety risk. Assessing the client’s intent to act on these commands is the priority to ensure safety for the client and others.

D. “Do you believe the voices are real?”: Exploring the client’s perception of reality is relevant for treatment but is secondary to assessing immediate danger associated with violent command hallucinations.

A. Increase your water and fiber intake while taking opioids. B. Expect the morphine to take 1 to 2 hours for full effect. C. Request pain medication only if pain is severe. D. Use incentive spirometer when the pain medication takes effect. E. Ask for assistance when getting out of bed after taking morphine.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Rationale for correct choices:

• Increase your water and fiber intake while taking opioids: Opioids frequently cause constipation by slowing gastrointestinal motility. Encouraging adequate hydration and fiber intake helps prevent constipation and maintain bowel regularity, which is an essential part of opioid education.

• Expect the morphine to take 1 to 2 hours for full effect: IV morphine typically takes effect within 5 to 10 minutes, with peak analgesic effect in about 20 minutes. Telling the client it takes 1 to 2 hours may cause confusion and unnecessary delay in using other comfort measures.

• Request pain medication only if pain is severe: Waiting until pain is severe can result in poor pain control and decreased participation in respiratory exercises. Encouraging timely administration before pain becomes severe promotes better analgesia and facilitates lung expansion.

• Use incentive spirometer when the pain medication takes effect: Pain can limit the client’s ability to perform deep breathing exercises. Using the incentive spirometer when analgesia is effective promotes lung expansion, reduces atelectasis risk, and improves oxygenation in clients with rib fractures.

• Ask for assistance when getting out of bed after taking morphine: Morphine can cause dizziness, orthostatic hypotension, or sedation, increasing fall risk. Asking for assistance ensures client safety during ambulation or position changes, especially in older adults with recent trauma.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A college student brings a dorm roommate to the campus clinic because the roommate has been talking to someone who is not present. The client tells the nurse that the voices are saying, "Kill, kill." Which question should the nurse ask the client next?

Correct Answer is C

Explanation

Patient Data Exhibits The nurse is providing education about opioid pain medication. For each education point, click to indicate whether it is appropriate or not appropriate to provide to the client. Each row must have one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"}}

Explanation

Patient Data Exhibits The client is seen for a 1 week follow up appointment. The nurse is evaluating the response to the treatment for cellulitis. Select the 3 findings consistent with a therapeutic response to interventions.

Patient Data Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once day for a client who weighs 154 pounds. The medication is available in 25,000 units/mL vial. How many mL should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)

Which task should the nurse delegate to an unlicensed assistive personnel (UAP)?

The nurse is planning a class about blood glucose monitoring for a group of clients with diabetes mellitus. Which timing of glucose testing would apply for any client regardless of the client's age or type of diabetes?