A nurse is prioritizing care for two clients at the start of the shift. The first client, who is 1 day postoperative following a partial bowel resection, requires a dressing change, total parenteral nutrition administration, and reports a pain level of 6 on a scale from 0 to 10. The second client, who has a newly inserted percutaneous gastrostomy tube, requires a tube feeding, dressing change, and daily weight. Which of the following nursing actions should the nurse plan to complete first?

Administer pain medication to the first client.

Weigh the second client.

Change the dressings of both clients.

Obtain vital signs for both clients.

Answer and Explanation

The Correct Answer is A

A. Administer pain medication to the first client: Pain management is a priority, especially for a postoperative patient with a pain level of 6 out of 10. Addressing pain can improve the client’s comfort and ability to participate in other aspects of care, such as nutrition administration and mobility.

B. Weigh the second client: While important for monitoring nutritional status, weighing the client is not as urgent as managing pain for a postoperative patient.

C. Change the dressings of both clients: Dressing changes are necessary but can be scheduled after addressing the more immediate needs such as pain management for the postoperative client.

D. Obtain vital signs for both clients: While vital signs are important for assessing overall health, pain management should be prioritized to address the immediate discomfort and potential impacts on recovery.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is C

Explanation

A. Losartan 50.0 mg, PO, QD: The use of decimal points with trailing zeros (50.0 mg) is discouraged to avoid potential errors. It should be written as 50 mg.

B. Desmopressin .1 mL, intranasal, qd: The abbreviation "qd" (quaque die) is not recommended due to potential misinterpretation. It should be written as "daily."

C. Metformin 500 mg, 1 tablet, PO, daily: This prescription is clear and correctly formatted, including the dosage, route, and frequency without ambiguous abbreviations.

D. Zolpidem, 5 mg PO, HS: The abbreviation "HS" (at bedtime) is acceptable, but clarity and standardization are preferred, and this option is less specific compared to C.

A. The client has not been taking the medication properly B. The client has become addicted to the medication C. The client developed a tolerance to the medication D. The client is experiencing episodes of confusion

Correct Answer is C

Explanation

A. The client has not been taking the medication properly: Increased dosage is usually due to the body's adaptation to the medication, not improper use.

B. The client has become addicted to the medication: Addiction is characterized by compulsive use, not necessarily by increased dosage for pain relief.

C. The client developed a tolerance to the medication: Tolerance occurs when the body becomes used to a drug, necessitating higher doses to achieve the same effect, which explains the need for a dosage increase.

D. The client is experiencing episodes of confusion: Confusion is not a typical explanation for needing an increased dose of morphine; it may indicate another issue requiring separate assessment.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching a newly licensed nurse about transcribing prescriptions. Which of the following examples should the nurse include in the instructions?

Correct Answer is C

Explanation

A hospice nurse is caring for a client who has terminal cancer and takes PO morphine for pain relief. The client reports that he had to increase the dose of morphine this week to obtain pain relief. Which of the following scenarios should the nurse document as the explanation for this situation?

Correct Answer is C

Explanation

A nurse is completing a client's history and physical examination. Which of the following information should the nurse consider subjective data?

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention?

A nurse is administering timolol eye drops to a client who has glaucoma. Which of the following actions should the nurse take?

A nurse is receiving change-of-shift report for a group of assigned clients. The nurse anticipates which of the following activities first in delivering client care using the nursing process?

A nurse is giving a presentation about client confidentiality to a group of newly licensed nurses. Which of the following actions is an example of a violation of confidentiality?

A nurse is receiving a provider's prescription for a client via telephone. Which of the following actions should the nurse take to ensure the accuracy of the telephone prescription? (Select all that apply.)

A nurse is orienting a newly licensed nurse about documentation of a client's information in the electronic health record. Which of the following statements by the newly licensed nurse indicates understanding of the purpose of documentation?