A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Tachycardia

Lacrimation

Hypertension

Urinary retention

Answer and Explanation

The Correct Answer is D

The correct answer is D. Urinary retention. Morphine is an opioid analgesic that can cause urinary retention by inhibiting bladder contractions and increasing sphincter tone. Urinary retention can lead to urinary tract infections, bladder distension, and renal impairment if not treated.

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Correct Answer is C

Explanation

The client should wrap the leg with an elastic bandage to reduce swelling and promote healing.

The client should not maintain bed rest, as this can increase the risk of thrombosis and infection.

The client should elevate the leg above the heart level, not keep it in a dependent position, as this can reduce venous pressure and edema.

The client does not need to implement a sodium-restricted diet, as this is not related to vein stripping.

A. Irrigation of a wound with antibiotic solution B. Placement of a central venous catheter C. Insertion of a nasogastric tube D. Administration of an iron injection using the Z-track technique

Correct Answer is B

Explanation

The correct answer is B. Placement of a central venous catheter.

Rationale: The nurse should identify that informed consent is required for the placement of a central venous catheter, as this is an invasive procedure that carries significant risks and benefits that need to be explained to the client before obtaining consent. Informed consent is not required for irrigation of a wound with antibiotic solution, as this is a routine nursing intervention that does not involve significant risks or benefits.

Informed consent is not required for the insertion of a nasogastric tube, as this is a common nursing procedure that does not involve significant risks or benefits. Informed consent is not required for the administration of an iron injection using the Z-track technique, as this is a standard medication administration technique that does not involve significant risks or benefits.

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A nurse is caring for a client who is receiving morphine for pain. Which of the following findings indicates that the client is experiencing an adverse effect of the medication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing discharge teaching with a client who has undergone a vein stripping of the right leg. Which of the following instructions should the nurse include in the teaching?

Correct Answer is C

Explanation

A nurse is reviewing the plan of care for a group of clients. The nurse should identify that informed consent is required for which of the following procedures?

Correct Answer is B

Explanation

A nurse is implementing a bladder training program for a client who had a stroke. Which of the following interventions should the nurse take first?

A nurse and an assistive personnel (AP) are repositioning a client who is immobile up in bed using a draw sheet. The nurse should instruct the AP to take which of the following actions?

A nurse is collecting data from a client who has pyelonephritis and is receiving gentamicin via IV infusion. Which of the following manifestations should the nurse identify as an adverse effect of the treatment?

A nurse is reviewing the medical record of a client. These are the medical reports; Hypoactive bowel sounds upon auscultation, abdomen soft, not distended on palpation and urinary output of 130mL/4hr. Which of the following findings should the nurse report to the provider?

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A nurse is talking with a client who refuses a blood transfusion for religious reasons. Which of the following responses should the nurse make?

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