a client with terminal cancer is receiving a continuous intravenous infusion of morphine sulfate on assessment of the client what does the nurse check
Logo

Nursing Elites

NCLEX-PN

NCLEX PN Test Bank

1. When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?

Correct answer: B

Rationale: When assessing a client with terminal cancer receiving morphine sulfate via continuous intravenous infusion, the nurse's priority should be checking the client's respiratory status first. Morphine sulfate can lead to respiratory depression, emphasizing the need for close monitoring of breathing. While temperature, pulse, and urine output are all essential components of the assessment, ensuring adequate respiratory function takes precedence due to the potential risk of respiratory depression associated with morphine sulfate. Promptly assessing respiratory status enables early identification of any signs of respiratory distress or depression, allowing for immediate intervention if needed.

2. Under what circumstances can an individual receive medical care without giving informed consent?

Correct answer: B

Rationale: An individual may receive medical care without giving informed consent in an emergency, life-or-death situation. This exception allows healthcare providers to provide immediate treatment to save a person's life or prevent serious harm when time is of the essence. Choices A, C, and D are incorrect because in all other situations, informed consent is required. The durable power of attorney for health care should be involved if available, the physician should have a discussion with the client in non-life-threatening situations, and in cases where clients are unable to speak for themselves, their designated representative or responsible party should be involved in the consent process.

3. A client with a pleural drainage system to suction has gentle bubbling of the water seal. What should the nurse do?

Correct answer: D

Rationale: Gentle bubbling is a normal finding for a client with a pleural drainage system to suction, so it simply needs to be documented for monitoring purposes. If the bubbling becomes vigorous, it could indicate a leak, which would then require further investigation by the nurse. Therefore, the correct action at this point is to document the finding. Notifying the physician is not necessary for gentle bubbling as it is expected. Clamping the chest tube or replacing the system is inappropriate and could potentially harm the client as there is no indication for such actions based on the scenario provided.

4. The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate a need for teaching reinforcement?

Correct answer: A

Rationale: The correct answer is, "Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often."? This statement indicates a need for teaching reinforcement because even when an NG tube is in place, the client should still brush their teeth twice daily. Good oral hygiene is essential to reduce the risk of introducing bacteria that may cause an infection. Choice B is incorrect because remaining sitting up at a 45-degree angle or higher for 30 minutes after a feeding is a correct statement regarding NG tube care, promoting proper digestion and reducing the risk of aspiration. Choice C is also incorrect because cleaning around the tube with water and mild soap is an appropriate practice to maintain cleanliness and prevent infection. Choice D is incorrect because advising to avoid using Vaseline around the nostril and tube is a proper instruction to prevent skin breakdown, occlusion of the tube, and potential aspiration of Vaseline into the lungs.

5. Which of the following medications might cause upper-gastrointestinal (UGI) bleeding?

Correct answer: C

Rationale: Naprosyn (naproxen) is known to cause upper-gastrointestinal (UGI) bleeding due to its effects on the stomach lining. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the stomach and increase the risk of UGI bleeding. On the other hand, Cardizem (diltiazem), Elavil (amitriptyline), and Corgard (nadolol) are not typically associated with UGI bleeding. Cardizem is a calcium channel blocker used for hypertension and angina, Elavil is a tricyclic antidepressant, and Corgard is a beta-blocker used for hypertension.

Similar Questions

A nursing instructor asks a nursing student to describe accountability. Which statement(s) by the student indicate(s) an accurate description of accountability?
During a hospital program about in vitro fertilization, a television crew arrives to film for a series on hospital services. What action should the nurse conducting the program take?
A client who is immobilized secondary to traction is complaining of constipation. Which of the following medications should the nurse expect to be ordered?
Ethical and moral issues concerning restraints include all of the following except:
Which of the following behaviors is least appropriate when dealing with fellow staff members?

Access More Features

NCLEX PN Basic
$69.99/ 30 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

NCLEX PN Premium
$149.99/ 90 days

  • 5,000 Questions with answers
  • Comprehensive NCLEX coverage
  • 30 days access

Other Courses