a nurse is preparing to administer a dose of hydrocodone which of the following should the nurse assess first
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PN ATI Capstone Proctored Comprehensive Assessment 2020 B with NGN

1. A healthcare professional is preparing to administer a dose of hydrocodone. Which of the following should the healthcare professional assess first?

Correct answer: A

Rationale: When administering hydrocodone, a healthcare professional should assess the respiratory rate first because hydrocodone is an opioid that can lead to respiratory depression. Monitoring the respiratory rate helps to detect any signs of respiratory distress or depression early on. Assessing blood pressure, pain level, or heart rate is also important but not the priority when administering hydrocodone, as the risk of respiratory depression is a more critical concern.

2. A nurse is providing education to a client who is 28 weeks pregnant and at risk for preterm labor. Which of the following signs should the nurse instruct the client to report immediately?

Correct answer: A

Rationale: Lower back pain, especially if accompanied by uterine contractions or pressure, can be a sign of preterm labor. The client should report this immediately to prevent complications or early delivery. Shortness of breath (Choice B), decreased fetal movement (Choice C), and nausea and vomiting (Choice D) can be common during pregnancy but are not typically associated with preterm labor. While they should be monitored, they are not immediate signs of concern for preterm labor.

3. A nurse is preparing to administer a measles, mumps, rubella (MMR) immunization to a child. Which is a contraindication for this vaccine?

Correct answer: A

Rationale: The correct answer is A: Recent blood transfusion. A recent blood transfusion can interfere with the effectiveness of the MMR vaccine, making it a contraindication. Choice B, allergy to penicillin, is not a contraindication for the MMR vaccine. Choice C, minor acute illness, is not a contraindication unless the child has a moderate to severe illness. Choice D, low-grade fever, is not a contraindication as long as the child does not have a moderate to severe febrile illness.

4. A nurse is performing a cultural assessment of a group of clients to maintain respect for their value systems and beliefs. Which of the following should the nurse identify as examples of cultural variables?

Correct answer: D

Rationale: In a cultural assessment, it is essential to consider various cultural variables that can impact communication and interactions. Eye contact, personal space, and touch are examples of cultural variables that can vary among different cultural groups. These variables influence how individuals perceive and engage in communication. Understanding and respecting these differences are crucial for effective and culturally sensitive care. Therefore, the correct answer is 'All of the above.' Choices A, B, and C are incorrect because each of them represents a cultural variable that should be considered during a cultural assessment.

5. A client with rheumatoid arthritis is taking prednisone. Which of the following findings should the nurse identify as an adverse effect of this medication?

Correct answer: C

Rationale: The correct answer is C: Hypertension. Prednisone, a corticosteroid, can lead to hypertension as an adverse effect. Prednisone can cause sodium and water retention, leading to increased blood pressure. Options A, B, and D are incorrect. Weight loss is not typically associated with prednisone use; instead, weight gain is more common. Hypoglycemia is not a common adverse effect of prednisone; in fact, it can elevate blood sugar levels. Hyperkalemia is also not a typical adverse effect of prednisone; instead, it can cause hypokalemia, or low potassium levels.

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