When collecting data, the nurse understands which individual is the primary source of information regarding pain tolerance.

Patient

Patient's roommate

Certified Nursing Assistant (CNA)

Nurse

Answer and Explanation

The Correct Answer is A

A. The patient is the primary source of information regarding their pain tolerance, as pain is subjective and only the patient can accurately describe their experience.

B. A patient's roommate cannot reliably report on the patient's pain experience.

C. The CNA may observe signs of pain but cannot determine the patient's subjective pain tolerance.

D. The nurse can assess the patient's pain based on behaviors and reports but relies on the patient for direct information.

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Correct Answer is B

Explanation

A. Stage III pressure ulcers are characterized by full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer appears as a deep crater, and there may be damage to the surrounding tissue.
B. The above image depicts an Unstageable pressure ulcers since the base of the ulcer is covered by slough in the wound bed.
C. The term 'necrotic stage I' is not typically used in the staging of pressure ulcers. Necrosis refers to dead tissue, which is not present in a Stage I pressure ulcer. Stage I ulcers are characterized by intact skin with non-blanchable redness of a localized area usually over a bony prominence.

D. Stage II pressure ulcers involve partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed or as an intact or ruptured blister. The ulcer is painful and may appear as a shiny or dry shallow ulcer without slough or bruising.

Correct Answer is ["0.8"]

Explanation

To administer the correct dose of morphine sulfate, which is prescribed at 8 mg stat, and given that the medication ampule concentration is 10 mg/mL, the nurse would need to calculate the volume of medication to administer. The calculation is based on the formula: Volume (mL) = Dose (mg) / Concentration (mg/mL). Therefore, for an 8 mg dose, the nurse would prepare 0.8 mL of morphine sulfate to administer, rounding to the nearest tenth.

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When collecting data, the nurse understands which individual is the primary source of information regarding pain tolerance.

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Naxlex Comprehensive Predictor Exams

The nurse is admitting a client to the medical-surgical unit and notes the skin breakdown shown in the diagram. How should the nurse document the finding?

Correct Answer is B

Explanation

A prescription reads morphine sulfate, 8 mg stat. The medication ampule reads morphine sulfate, 10mg/ml. The nurse prepares how many milliliters (mL) to administer the correct dose. Round to the nearest tenth.

Correct Answer is ["0.8"]

Explanation

While checking the client's medication administration record, it was determined the client received the wrong medication. Which action should the nurse implement first?

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