A nurse receives a telephone prescription from the provider, who states, "Four milligrams of morphine diluted with five milliliters of sterile water, intravenously each morning at nine o'clock before client dressing changes." Which of the following entries by the nurse indicates correct transcription of the prescription?

MSO4 4 mg IV bolus daily before dressing changes and dilute with 5 cc of water.

Morphine 4 mg IV bolus daily at 0900 before dressing changes, dilute medication with 5 mL of sterile water.

Morphine 4 mg IV bolus Q.D. before dressing changes and dilute with 5 cc of sterile water.

MSO4 4 mg IV bolus daily @9 AM, dilute with 5 mL of sterile water.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

While the abbreviation "MSO4" represents morphine sulfate, it is safer to spell out the medication name to prevent misinterpretation. Also, the use of "cc" for volume and lack of clarity in timing make this option less desirable.

Choice B rationale:

(Correct Choice) This option correctly identifies the medication, includes the dose (4 mg), specifies the route (IV), indicates the timing (daily at 0900 before dressing changes), and provides instructions for dilution (5 mL of sterile water).

Choice C rationale:

Using "Q.D." is an abbreviation for "every day" and might lead to confusion due to unfamiliarity. Additionally, using "cc" instead of "mL" and lack of clarity in timing reduce the accuracy of this transcription.

Choice D rationale:

Using "MSO4" and "cc" are potential sources of confusion. Also, the abbreviation "@9 AM" might not be universally understood, and "mL" is a more appropriate unit for volume.

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Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Ambulation assistance is expected in rehabilitation. It reflects motor recovery needs but does not pose an immediate safety or health risk requiring urgent referral.

Choice B rationale: Difficulty using utensils indicates fine motor deficits. While important for occupational therapy, it’s not a priority compared to airway protection concerns.

Choice C rationale: Expressive aphasia affects communication but does not compromise physical safety or airway integrity. Speech therapy is appropriate but not urgent.

Choice D rationale: Coughing after drinking signals aspiration risk. This can lead to pneumonia or airway obstruction, requiring immediate referral to speech-language pathology for swallow evaluation.

A. Teach the most crucial content early in the session. B. Assume that the learners have no prior knowledge of first aid. C. Avoid repetition of procedures and techniques. D. Divide the planned program into several sessions held about 1 week apart.

Correct Answer is A

Explanation

Choice A rationale:

Teaching the most crucial content early in the session is an effective strategy to engage learners and ensure that they receive essential information. This approach captures their attention and provides a solid foundation for the rest of the session. It helps establish relevance and interest, keeping the learners engaged throughout the educational program.

Choice B rationale:

Assuming that learners have no prior knowledge of first aid might not be the best approach. Adult learners often come with varying levels of knowledge and experience. It's important to assess the learners' prior knowledge and adjust the content accordingly to avoid redundancy or information that is too basic for them.

Choice C rationale:

Repetition of procedures and techniques is a valuable teaching strategy. Repetition aids in retention and comprehension. Reiterating important points reinforces learning and helps participants remember critical steps in first aid procedures. Avoiding repetition can lead to incomplete understanding and retention.

Choice D rationale:

Dividing the planned program into several sessions held about 1 week apart might not be the most effective strategy for community education. Spacing the sessions too far apart could result in learners forgetting the content or losing interest. It's better to maintain a consistent schedule to ensure continuity and engagement.

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Naxlex Comprehensive Predictor Exams

A nurse in a rehabilitation unit is assessing a group of clients who have a traumatic brain injury. The nurse should identify that which of the following clients requires a priority referral?

Correct Answer is D

Explanation

A nurse is planning a community education session about the basic principles of first aid. Which of the following teaching strategies should the nurse implement for a group of adult learners in a community setting?

Correct Answer is A

Explanation

A nurse is preparing to notify the provider about a change in a client's status. Which of the following information should the nurse plan to include in the "background" portion of the Situation, Background, Assessment, Recommendation (SBAR) Communication tool?

A nurse is providing discharge teaching to a client who will be using a cane to maintain mobility at home following a left knee arthroplasty. Which of the following statements by the client indicates an understanding of the safe use of a cane?

A nurse is providing teaching to a client who has a new colostomy. Which of the following actions should the nurse take when demonstrating how to change the ostomy appliance?

A nurse is planning care for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse include to reduce the client's risk for ventilator-associated pneumonia?

A nurse is caring for a postoperative client and observes evisceration of the abdominal surgical wound. After covering the wound with a sterile, saline-soaked dressing, which of the following actions should the nurse take?

A nurse is caring for a client who has Alzheimer's disease and appears anxious. The client asks the nurse to stay at their bedside. Which of the following responses should the nurse make to reduce the client's anxiety?

A nurse is teaching a client about self-administering a subcutaneous injection to the abdomen. Which of the following instructions should the nurse include?

A home health nurse is teaching a client who has a latex allergy about items typically found in the home that can trigger an allergic reaction. Which of the following items should the nurse instruct the client to avoid? (Select all that apply.).