Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has acute heart failure and received morphine IV 30 min ago. Which of the following findings should the nurse identify as an indication that the medication was effective?
A. Emesis of 250 mL
Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. Increased respiratory rate to 26/min
While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
C. Decreased anxiety
Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
D. Decreased urinary output
Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.
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Full Explanation
C. Morphine is a central nervous system depressant that can help decrease anxiety and relieve dyspnea in clients with acute heart failure. Therefore, a decrease in anxiety would indicate that the medication has been effective in achieving its intended outcome.
A. Emesis, or vomiting, is not an expected outcome of morphine administration in the context of acute heart failure.
B. While morphine can help alleviate dyspnea, an increased respiratory rate may indicate respiratory distress rather than effective symptom relief.
D. Morphine does not directly affect urinary output, and a decrease in urinary output may indicate other issues such as renal dysfunction or fluid overload.
Similar Questions
A nurse is taking an admission history from a client who reports Raynaud's disease. Which of the following assessment findings should the nurse identify as a potential trigger for exacerbations of Raynaud's?
A. A history of herpes zoster
While herpes zoster (shingles) is a viral infection caused by the varicella-zoster virus, it is not directly associated with triggering Raynaud's attacks.
B. Taking amlodipine for hypertension
Amlodipine is a calcium channel blocker medication commonly used to treat hypertension.
C. Using a nicotine transdermal patch
Nicotine is a vasoconstrictor, meaning it causes narrowing of blood vessels. Therefore, using a nicotine transdermal patch can exacerbate Raynaud's attacks by promoting vasoconstriction and reducing blood flow to the extremities.
D. Eating a strict vegetarian diet
While diet can potentially influence overall health and vascular function, there is no direct evidence to suggest that a strict vegetarian diet would trigger exacerbations of Raynaud's disease.
Full Explanation
C. Nicotine is a vasoconstrictor, meaning it causes narrowing of blood vessels. Therefore, using a nicotine transdermal patch can exacerbate Raynaud's attacks by promoting vasoconstriction and reducing blood flow to the extremities.
A. While herpes zoster (shingles) is a viral infection caused by the varicella-zoster virus, it is not directly associated with triggering Raynaud's attacks.
B. Amlodipine is a calcium channel blocker medication commonly used to treat hypertension.
D. While diet can potentially influence overall health and vascular function, there is no direct evidence to suggest that a strict vegetarian diet would trigger exacerbations of Raynaud's disease.
A nurse working in the emergency department is caring for a client who has a burn injury. After securing the client's airway, which of the following interventions should the nurse take first?
A. Increase the room temperature.
Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. Cleanse the client's wounds.
While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Administer analgesic medication.
Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention
D. Start an IV with a large-bore needle.
Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
Full Explanation
D. Start an IV with a large-bore needle. Establishing intravenous access is crucial for fluid resuscitation and administering medications. It allows for timely administration of fluids and other necessary treatments to stabilize the client’s condition.
A. Increasing the room temperature is not a priority intervention for a client with a burn injury, especially immediately after securing the airway.
B. While wound care is essential in the management of burn injuries, it is not the first intervention to prioritize after securing the airway.
C. Burn injuries can be extremely painful, and providing analgesic medication is important but not a priority intervention
A nurse is providing discharge teaching for a client who has heart failure and is to start therapy with digoxin. Which of the following statements by the client indicates an understanding of the teaching?
A. "I will take this medication with fiber to prevent constipation."
While constipation is a potential side effect of digoxin, taking it with fiber is not a recommended method for preventing constipation.
B. "I will notify my provider if I experience muscle weakness."
Muscle weakness can be a sign of digoxin toxicity, and it is essential for the client to notify their healthcare provider if they experience this symptom. Muscle weakness is a potential adverse effect of digoxin, especially if the medication level in the blood becomes too high.
C. "I will increase my dose if my vision becomes blurred."
Blurred vision can be a sign of digoxin toxicity, and the client should not increase their dose if they experience this symptom. Instead, they should promptly notify their healthcare provider to assess for toxicity and adjust the medication regimen as needed.
D. "I will take my digoxin if my pulse is less than 50 beats per minute."
Digoxin is a medication that can slow the heart rate, and a pulse rate less than 60 beats per minute is considered bradycardia. If the client's pulse is less than 60 beats per minute, they should hold the digoxin and promptly notify their healthcare provider.
Full Explanation
B. Muscle weakness can be a sign of digoxin toxicity, and it is essential for the client to notify their healthcare provider if they experience this symptom. Muscle weakness is a potential adverse effect of digoxin, especially if the medication level in the blood becomes too high.
A. While constipation is a potential side effect of digoxin, taking it with fiber is not a recommended method for preventing constipation.
C. Blurred vision can be a sign of digoxin toxicity, and the client should not increase their dose if they experience this symptom. Instead, they should promptly notify their healthcare provider to assess for toxicity and adjust the medication regimen as needed.
D. Digoxin is a medication that can slow the heart rate, and a pulse rate less than 60 beats per minute is considered bradycardia. If the client's pulse is less than 60 beats per minute, they should hold the digoxin and promptly notify their healthcare provider.