a nurse is reviewing the medical record of a client who is receiving morphine for pain management which of the following findings should the nurse rep
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Nursing Elites

ATI RN

ATI Comprehensive Exit Exam 2023 With NGN

1. A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.

2. What is the best intervention for a patient experiencing respiratory distress?

Correct answer: A

Rationale: Administering oxygen is the best intervention for a patient experiencing respiratory distress because it helps improve oxygenation and alleviate respiratory distress. Oxygen therapy is a critical and priority intervention in such cases as it aims to increase oxygen levels in the blood. Administering bronchodilators may be beneficial for specific respiratory conditions like asthma or COPD, but oxygen should be the initial priority. Administering IV fluids and providing humidified air, while important in certain situations, are not the primary interventions for respiratory distress.

3. When caring for a client with a new prescription for enoxaparin for the prevention of DVT, what is an appropriate action by the nurse?

Correct answer: C

Rationale: When administering enoxaparin for the prevention of DVT, the nurse should inject the medication into the lateral abdominal wall. This site is preferred for subcutaneous injections of enoxaparin to reduce the risk of bleeding or injury. Expelling air bubbles, massaging the injection site, or administering an NSAID for discomfort are not appropriate actions and could lead to complications or ineffective medication delivery.

4. A client has a new prescription for digoxin. Which of the following statements should the nurse include?

Correct answer: C

Rationale: The correct statement for the nurse to include when teaching a client about digoxin is to 'Take your pulse before taking this medication.' This is essential because clients taking digoxin need to monitor their pulse to detect signs of bradycardia, a common adverse effect of the medication. Option A is incorrect because digoxin is usually recommended to be taken with food to avoid gastrointestinal upset. Option B is incorrect because antacids can interfere with the absorption of digoxin. Option D is incorrect because contacting the provider for visual changes is important, but monitoring the pulse is crucial for digoxin administration.

5. A nurse is reviewing the medical record of a client who has diabetes insipidus. Which of the following findings should the nurse expect?

Correct answer: B

Rationale: Polyuria is the correct answer. Diabetes insipidus is characterized by the inability to concentrate urine, leading to excessive urination (polyuria) and thirst. Bradycardia (slow heart rate) is not typically associated with diabetes insipidus. While dehydration from the excessive urination can lead to hypotension rather than hypertension, and weight loss can occur due to fluid loss, the most specific and significant finding expected in diabetes insipidus is polyuria.

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