A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles." Which of the following actions should the nurse take?

Request a change in the medication route to PO.

Remind the client that they must receive the medication as prescribed.

Tell the client not to worry because the pain will be temporary.

Ask one of the client's loved ones to encourage them to receive the IM

Answer and Explanation

The Correct Answer is A

A)   Request a change in the medication route to PO. - If the client is afraid of needles, and if methadone can be effectively administered orally (PO), changing the route of administration to oral may be a reasonable alternative.
B)   Remind the client that they must receive the medication as prescribed. - While important to ensure adherence to the prescribed treatment, it's also essential to address the client's concerns and preferences.
C)   Tell the client not to worry because the pain will be temporary. - Dismissing the client's fear with reassurance about temporary pain may not adequately address their anxiety.
D)   Ask one of the client's loved ones to encourage them to receive the IM medication.

- Involving loved ones may be helpful, but the client's preference should be respected, and alternative options should be explored.

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Correct Answer is B

Explanation

A) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

B) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

C) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

D) To calculate the intake volume for the I&O chart, the nurse should convert all liquid measurements to milliliters. One ounce is approximately 30 milliliters. Therefore, 8 oz of milk is 240 mL, 10 oz of water is 300 mL, and 4 oz of gelatin (since it's considered a liquid for I&O purposes) is 120 mL. The egg, bacon, and biscuits are not included in the liquid intake calculation. Adding up the liquids, the total intake is 240 mL + 300 mL + 120 mL, which equals 660 mL.

A. Use a narrower cuff to repeat the BP measurement. B. Request a prescription for an antihypertensive medication. C. Deflate the cuff faster when repeating the BP measurement. D. Measure the client's BP in the other arm.

Correct Answer is D

Explanation

A) Use a narrower cuff to repeat the BP measurement. - Using a narrower cuff is not appropriate and may result in inaccurate BP readings.
B) Request a prescription for an antihypertensive medication. - This action is premature based on a single elevated BP reading and should be guided by the provider's assessment and recommendations.
C) Deflate the cuff faster when repeating the BP measurement. - The speed of cuff deflation does not significantly affect BP measurement accuracy, and this action may not address the underlying cause of the elevated BP.
D) Measure the client's BP in the other arm. - Confirming the elevated BP with a reading from the other arm can help determine if the elevation is due to positioning or equipment error.

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A nurse is caring for a client who is receiving detoxification treatment for an opioid use disorder. As the nurse is preparing to administer a methadone IM injection, the client tells the nurse, "I am afraid of needles." Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is recording the intake and output (I&O) for a client. The client consumed 8 oz of milk, 10 oz of water, 4 oz of gelatin, 1 egg, 1 piece of bacon, and 2 biscuits. Which of the following volumes should the nurse record on the I&O?

Correct Answer is B

Explanation

A nurse on a medical-surgical unit is collecting data from a client who is postoperative following abdominal surgery. The client's BP was 126/72 mm Hg 15 min ago. The nurse now finds that the client's BP is 176/96 mm Hg. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

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