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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale:

The client's statement about increasing daily intake of calcium and vitamin D indicates an understanding of the teaching related to kyphosis and osteoporosis. Kyphosis is a condition where there is an abnormal curvature of the spine, leading to a hunched-back appearance, and osteoporosis is a condition characterized by weakened bones. Calcium and vitamin D are essential nutrients for maintaining bone health. Calcium is a mineral that is a major component of bones, and vitamin D helps the body absorb calcium from the diet. Adequate intake of these nutrients is crucial for preventing further bone loss and fractures in individuals with kyphosis and osteoporosis.

Choice B rationale:

The client's statement about scheduling an electrophysiologic study is unrelated to the teaching about kyphosis and osteoporosis. Electrophysiologic studies are used to evaluate the electrical activity of the heart, and they are not directly relevant to the client's bone health or the management of kyphosis and osteoporosis.

Choice C rationale:

The client's statement about wearing a neck brace while sleeping to prevent injury is incorrect and indicates a misunderstanding of the teaching. Kyphosis primarily affects the thoracic (upper/mid-back) spine and is not typically associated with wearing a neck brace. Neck braces are more commonly used for cervical spine issues.

Choice D rationale:

The client's statement about avoiding weight-bearing exercise to minimize trauma is incorrect and demonstrates a misunderstanding of the teaching. Weight-bearing exercise, such as walking and strength training, is important for maintaining bone density and muscle strength, which are critical for individuals with kyphosis and osteoporosis. Avoiding weight-bearing exercise could actually lead to further bone loss and weakness.

A. Request additional information about the caller's relationship to the client. B. Provide a general update about the client's condition over the telephone. C. Refer the family member to the client's provider for the update. D. Encourage the family member to contact the client directly for information.

Correct Answer is C

Explanation

Choice A rationale:

Request additional information about the caller's relationship to the client. Rationale: While understanding the caller's relationship to the client is important for confirming the legitimacy of the request, it doesn't address the core concern of maintaining client confidentiality. Sharing information with individuals solely based on their relationship can still lead to breaches in privacy.

Choice B rationale:

Provide a general update about the client's condition over the telephone. Rationale: Providing a general update over the telephone is not a secure method of maintaining client confidentiality. General updates can inadvertently disclose sensitive information and should only be communicated through secure and private channels.

Choice C rationale:

Refer the family member to the client's provider for the update. Rationale: This choice is the correct answer as it ensures that the family member receives accurate and appropriate information from the authorized source, which is the client's healthcare provider. This approach maintains the confidentiality of the client's medical information and adheres to privacy regulations.

Choice D rationale:

Encourage the family member to contact the client directly for information. Rationale: Encouraging direct contact between the family member and the client for information sharing can potentially compromise the client's privacy. The client might not want their condition disclosed to certain individuals, and it's the responsibility of the healthcare provider to ensure that sensitive information is shared appropriately and securely.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing teaching to an older adult client who has kyphosis and osteoporosis. Which of the following client statements indicates an understanding of the teaching?

Correct Answer is A

Explanation

A nurse receives a telephone call from a client's family member, who asks the nurse for an update on the client's condition. Which of the following actions should the nurse take to maintain the client's confidentiality?

Correct Answer is C

Explanation

A nurse is planning care for a client who reports having difficulty sleeping. Which of the following interventions should the nurse include in the plan of care?

A nurse is preparing to administer an oral opioid analgesic to a client. Which of the following actions should the nurse take when handling an unused portion of the medication after administration?

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 planning care for a client who has a fever due to an infection. Which of the following interventions should the nurse include in the plan of care?

A nurse is caring for a client who is at risk for pressure injury formation due to immobility. The nurse should place the client in which of the following positions to reduce pressure on the client's bony prominences?

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?

A nurse is performing a bladder irrigation for a client who has an indwelling urinary catheter. Which of the following actions should the nurse take?

A nurse is caring for a client who reports using alcohol and controlled substances to cope with the death of their partner. The nurse should identify that maladaptive coping is an indication of which of the following types of complicated grief?