Patient Data

Exhibits

The nurse addresses the client's pain and plans interventions to reduce further complications.

Choose the most likely options for the information missing from the statements by selecting from the lists of options provided.

The nurse monitors the client's
dropdown
after administering the morphine. The nurse should include
dropdown
to reduce complications of the client's injury.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"A"}

Rationale for correct choices:

• Respirations: Morphine is an opioid analgesic that can depress the respiratory center in the brainstem, leading to slowed breathing and hypoventilation. Monitoring respirations after administration is critical to detect early signs of opioid-induced respiratory depression.

• Ice application to the shoulder: Applying ice reduces swelling, pain, and inflammation by causing vasoconstriction and limiting fluid accumulation at the injury site. For an acute humeral fracture with significant swelling and bruising, cold therapy is the appropriate intervention.

Rationale for incorrect choices:

• Nausea: While morphine can cause nausea and vomiting as side effects, they are not the most life-threatening concerns compared to respiratory depression. Monitoring nausea is appropriate but not the priority when evaluating opioid safety.

• Blood pressure: Morphine can cause hypotension, but this effect is less common and typically secondary to respiratory depression and vasodilation. Continuous monitoring of blood pressure is helpful, but respiratory monitoring takes priority in detecting opioid complications.

• Early active range of motion: Active movement of the injured arm is not recommended immediately after a displaced humeral fracture, as it can worsen displacement and interfere with healing. Immobilization and stabilization are required before introducing range-of-motion exercises.

• Heat application to the shoulder: Heat increases blood flow to tissues, which can worsen swelling and bleeding in the acute phase of injury. Applying heat too soon after a fracture increases the risk of complications rather than reducing them.

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Correct Answer is D

Explanation

A.Monitoring an intravenous infusion rate involves the assessment of fluid delivery and the mechanical function of medical equipment. This task requires specialized knowledge of pharmacology and potential complications like infiltration or circulatory overload, which are outside the UAP's training. Only a licensed nurse can legally monitor and validate the accuracy of an IV pump schedule. Delegating this to unlicensed staff poses a significant risk for medication errors and fluid imbalances.

B. Titrate oxygen to the prescribed parameters: Adjusting oxygen requires clinical judgment and assessment of respiratory status, including oxygen saturation and signs of hypoxia. This is a nursing responsibility and cannot be delegated to a UAP.

C. Insert a urinary catheter for an uncomplicated client: Catheter insertion is a sterile procedure that requires nursing knowledge and skill. Delegation to a UAP is not permitted due to the risk of infection and need for proper technique.

D. Procuring blood or platelet products from the blood bank is a standard administrative task that falls within the UAP scope of practice. This activity does not require clinical judgment, nursing assessment, or the performance of a sterile procedure. The nurse remains responsible for the final verification of the blood product at the bedside, but the physical transport is a safe delegation. It allows the nurse to remain on the unit for higher-priority clinical duties.

A. A potty chair should be brought from home to maintain the current level of toileting skills. B. Children usually resume their toileting behaviors when they leave the hospital. C. Diapering will be provided since hospitalization is stressful to preschoolers. D. A retraining program will need to be initiated when the child returns home.

Correct Answer is B

Explanation

A. A potty chair should be brought from home to maintain the current level of toileting skills: While familiar items can offer comfort, regression in toileting is typically temporary and does not require special equipment to preserve skills.

B. Children usually resume their toileting behaviors when they leave the hospital: Hospitalization is a stressful event for preschoolers, and temporary regression in toileting is common. Reassuring parents that the child is likely to return to previous toileting behaviors once home helps reduce anxiety and supports normal developmental expectations.

C. Diapering will be provided since hospitalization is stressful to preschoolers: Diapering may be used for convenience or safety, but presenting it as necessary for all hospitalized children may cause unnecessary concern. It does not address the expected return to prior skills.

D. A retraining program will need to be initiated when the child returns home: Most children spontaneously resume previous toileting abilities without formal retraining. Only persistent regression after discharge would warrant intervention.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to an unlicensed assistive personnel (UAP)?

Correct Answer is D

Explanation

A 3-year-old client was successfully toilet trained prior to admission to the hospital for injuries sustained from a fall. The client's parents are very concerned that the child has regressed in toileting behaviors. Which information should the nurse provide to the parents?

Correct Answer is B

Explanation

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