Question

A nurse is assessing a client 1 5 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

Answer 1

Correct Answers:

Respiratory rate of 81min.

Rationale :

✅ Morphine sulfate is an opioid analgesic known to cause central nervous system depression, including respiratory depression, particularly when administered intravenously. ✅ A respiratory rate of 8 breaths per minute is significantly lower than the normal adult range (12–20/min) and represents an adverse and potentially life-threatening effect. ✅ Opioids depress the brainstem respiratory centers, reducing responsiveness to carbon dioxide levels in the blood. ✅ This requires immediate nursing intervention to prevent further hypoventilation, hypoxia, or respiratory arrest.

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Answer 2

Correct Answers:

Have you had a recent influenza infection?

Rationale :

🔥Guillain-Barré syndrome (GBS) often follows an acute infection, especially viral respiratory or gastrointestinal illnesses. 🔥 A recent influenza infection is a common trigger, initiating an autoimmune response where the immune system attacks peripheral nerves. 🔥 Identifying this link supports diagnosis. 🔥The other options are unrelated to the typical onset or pathophysiology of GBS.

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Answer 3

Correct Answers:

MRI of the chest

Rationale :

🔥MRI is contraindicated in clients with permanent pacemakers unless the device is MRI-compatible. 🔥The magnetic field can interfere with pacemaker function, leading to potentially fatal dysrhythmias or device malfunction. 🔥Clarifying this prescription is essential to ensure client safety. 🔥Other prescriptions like physical therapy, cardiac enzyme levels, and a low-sodium diet are routine and safe for this client.

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Answer 4

Correct Answers:

Hemorrhage

Rationale :

🔹Hemorrhage is the priority complication following a transurethral resection of the prostate (TURP). 🔹The prostate is highly vascular, and bleeding is common postoperatively. 🔹 Uncontrolled hemorrhage can lead to hypovolemia and shock. Early detection is critical. 🔹While pain, infection, and urinary retention are important, none pose as immediate a threat to life as active bleeding. 🔹The nurse should closely monitor urine output, color, and vital signs.

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Answer 5

Correct Answers:

"They are going to examine my gallbladder and ducts."

Rationale :

🔸An oral cholangiogram is a diagnostic imaging test used to visualize the gallbladder and bile ducts by administering a contrast agent orally. 🔸The contrast allows clear X-ray imaging of these structures to assess for gallstones or bile duct obstruction. 🔸The correct statement reflects understanding of the procedure’s purpose. The other responses confuse the cholangiogram with endoscopy, lithotripsy, or therapeutic interventions.

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Answer 6

Correct Answers:

A firm nodule with a hard crust.

Rationale :

🔸Squamous cell carcinoma (SCC) is a type of non-melanoma skin cancer that arises from the squamous epithelial cells of the skin. 🔸It often develops on sun-exposed areas such as the face, ears, neck, and hands. 🔸Clinically, it presents as a firm, red nodule or a rough, scaly lesion that may form a hard crust and ulcerate over time. 🔸This type of lesion tends to grow more quickly than basal cell carcinoma and has a higher risk of metastasis if not treated promptly. 🔸 Early detection and biopsy are essential for diagnosis and timely treatment. 🔸The appearance of a firm, crusted nodule should raise suspicion and warrant further investigation, making this the most concerning finding on skin assessment.

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Answer 7

Correct Answers:

Hyperkalemia

Rationale :

✅ In prerenal acute kidney injury (AKI), there is a sudden reduction in renal blood flow, typically from hypovolemia, hypotension, or decreased cardiac output. ✅This leads to decreased glomerular filtration rate (GFR) and impaired renal excretion of waste and electrolytes. ✅ Potassium, which is normally excreted by the kidneys, accumulates in the bloodstream, resulting in hyperkalemia. ✅ Elevated serum potassium is dangerous as it can lead to life-threatening cardiac arrhythmias, including ventricular fibrillation. ✅ Hyperkalemia is a critical laboratory finding in prerenal AKI and must be identified and managed promptly.

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Answer 8

Correct Answers:

Poor impulse control.

Rationale :

✅ A stroke in the right cerebral hemisphere typically results in behavioral and perceptual deficits, including poor impulse control, impaired judgment, and a lack of awareness of impairments (anosognosia). ✅ Clients may exhibit risky behaviors, neglect the left side of their body (left-sided neglect), and have trouble with spatial-perceptual relationships. ✅ Unlike strokes in the left hemisphere, which primarily affect language and speech, right-sided strokes more commonly impact safety awareness and emotional regulation. ✅ The nurse should anticipate and manage impulsivity through environmental safety measures and supervision to prevent injury during recovery.

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Answer 9

Correct Answers:

Metabolic Alkalosis, Partially Compensated.

Rationale :

✅ The ABG values show pH 7.6 (alkalosis), PaCO₂ 31 mmHg (low), and HCO₃ 25 mmol/L (normal). ✅ A high pH and low PaCO₂ with a normal bicarbonate level indicate respiratory alkalosis that is uncompensated. ✅ This acid-base disturbance often occurs due to hyperventilation, which reduces CO₂ levels in the blood. ✅ Common triggers include anxiety, pain, fever, trauma, and conditions causing hypoxia. ✅ The patient in the scenario experienced trauma, pain, and anxiety, which can induce respiratory alkalosis. ✅ Symptoms like muscle cramps, tingling, and paresthesia are consistent with this condition due to shifts in calcium ionization that accompany alkalosis.

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Answer 10

Correct Answers:

Drink 2 liters ot fluid each day while taking the medication.

Rationale :

🔹Allopurinol is a xanthine oxidase inhibitor prescribed to reduce uric acid levels in patients with gout. 🔹A key nursing consideration is to encourage adequate fluid intake, typically 2–3 liters per day unless contraindicated. 🔹 This helps prevent the formation of uric acid kidney stones, a possible adverse effect of the medication. 🔹 Maintaining hydration promotes renal excretion of uric acid and enhances therapeutic effectiveness. 🔹Clients should also avoid high-purine foods and monitor for signs of hypersensitivity, but fluid intake is an essential component of safe and effective therapy with allopurinol.

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RN Medsurg Nurs 224

No.

1 : A nurse is assessing a client 1 5 minutes after administering 2 mg of morphine sulfate via IV push. The nurse should identify which of the following findings as an adverse effect of the medication?

2 : A nurse is assessing a client who has a suspected diagnosis of Guillain-Barre syndrome (GBS). Which of the following questions should the nurse ask the client?

3 : A nurse is caring for a client who recently had surgery for the insertion of a permanent pacemaker. Which of the following prescriptions should the nurse clarify?

4 : A nurse is caring for a client who is postoperative following a transurethral resection of the prostate (TURP). Which of the following complications is the priority for the nurse to monitor?

5 : A nurse is talking with a client who has cholelithiasis and is about to undergo an oral cholangiogram. Which of the following client statements indicates to the nurse an understanding of the procedure?

6 : A nurse is performing an integumentary assessment for a client. Which of the following findings should the nurse identify as possible squamous cell carcinoma?

7 : A nurse is reviewing the laboratory test results from a client who has prerenal acute kidney injury (AKI). Which of the following electrolyte imbalances should the nurse expect?

8 : A nurse is caring for a client who had a stroke involving the right cerebral hemisphere. The nurse should monitor for which of the following findings?

10 : A nurse is teaching a client who has a new prescription for allopurinol for the treatment of gout. Which of the following instructions should the nurse include?

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