Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago.
Which of the following findings is the nurse’s priority?
A. Euphoria
euphoria, is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine. Euphoria is not a priority finding and does not indicate a serious complication of morphine.
B. Bradypnea
Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.
C. Constipation
is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system
D. Constipation
is wrong because sedation is another common side effect of morphine that affects the central nervous system. Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Comprehensive Predictor 2023 Exit Proctored Exam A. Take the full exam now
Full Explanation
The correct answer is choice B, bradypnea. Bradypnea is abnormally slow breathing, which can be a sign of life-threatening respiratory depression caused by morphine. Respiratory depression is the most serious adverse effect of morphine and can lead to coma and death if not treated promptly. Therefore, the nurse should monitor the child’s respiratory rate and oxygen saturation closely and be prepared to administer naloxone, an opioid antagonist, if needed.
Choice A, euphoria, is wrong because euphoria is a feeling of intense happiness or well-being that is a common side effect of morphine.
Euphoria is not a priority finding and does not indicate a serious complication of morphine.
Choice C, constipation, is wrong because constipation is a common and chronic side effect of morphine that affects the gastrointestinal system.
Constipation can cause discomfort and complications such as bowel obstruction, but it is not a priority finding compared to respiratory depression.
Choice D, sedation, is wrong because sedation is another common side effect of morphine that affects the central nervous system.
Sedation can impair the child’s level of consciousness and ability to respond to stimuli, but it is not as urgent as respiratory depression.
Similar Questions
A nurse on a medical-surgical unit is notified that a mass casualty event has occurred in the community.
Which of the following actions should the nurse plan to take
A. Call in additional medical-surgical unit nursing care staff
Calling in additional medical-surgical unit nursing care staff is not the most effective initial action. The immediate priority is to create space for incoming casualties, not necessarily increasing staffing levels immediately.
B. Act as a liaison between the facility and the media
Acting as a liaison between the facility and the media is not a primary responsibility for the nurse. This task typically falls to the facility's public relations team.
C. Determine the medical needs of incoming clients through the emergency department.
Determining the needs of incoming clients (triage) is performed by emergency department staff or designated triage officers at the scene, not by nurses working on a medical-surgical inpatient unit.
D. Recommend to the provider specific acute care clients for discharge.
To create bed capacity for incoming disaster victims, the medical-surgical nurse identifies stable clients who can safely be discharged or transferred, recommending these specific individuals to the healthcare provider.
E. None
None
F. None
None
Full Explanation
Choice A rationale: Calling in additional staff is typically a function of the nursing supervisor or the hospital’s incident command center, rather than the responsibility of a single medical-surgical unit nurse.
Choice B rationale: Acting as a media liaison is the role of the Public Information Officer. Nurses must maintain patient confidentiality and follow the established chain of command during a mass casualty event.
Choice C rationale: Determining the needs of incoming clients (triage) is performed by emergency department staff or designated triage officers at the scene, not by nurses working on a medical-surgical inpatient unit.
Choice D rationale: To create bed capacity for incoming disaster victims, the medical-surgical nurse identifies stable clients who can safely be discharged or transferred, recommending these specific individuals to the healthcare provider.
A nurse in an emergency department is caring for a client following a motor-vehicle crash.
The client’s Glasgow coma scale rating is 15.
Which of the following findings should the nurse expect
A. The client withdraws from pain
wrong because the client withdraws from pain. This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.
B. The client is unable to obey commands.
wrong because the client is unable to obey commands. This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.
C. The client opens eyes to sound
wrong because the client opens eyes to sound. This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening. The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.
D. The client is oriented times three
The client is oriented times three. This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.
Full Explanation
The correct answer is choice D. The client is oriented times three.
This means that the client knows who they are, where they are, and what time it is. This indicates a high level of consciousness and a normal Glasgow coma scale (GCS) rating of 15.
Choice A is wrong because the client withdraws from pain.
This means that the client reacts to a painful stimulus by pulling away from it. This indicates a lower level of consciousness and a GCS rating of 4 for motor response.
Choice B is wrong because the client is unable to obey commands.
This means that the client does not follow simple instructions such as moving a limb or opening their eyes. This indicates a lower level of consciousness and a GCS rating of 1 or 2 for motor response.
Choice C is wrong because the client opens eyes to sound.
This means that the client does not open their eyes spontaneously, but only when they hear a loud noise. This indicates a lower level of consciousness and a GCS rating of 3 for eye opening.
The Glasgow coma scale is a clinical tool used to assess the level of consciousness of a person after a brain injury.
It consists of three tests: eye opening, verbal response, and motor response.
Each test has a score range from 1 to 6, with higher scores indicating higher levels of consciousness. The total score ranges from 3 to 15, with lower scores indicating higher risk of death.
While performing a routine assessment, a nurse notices fraying on the electrical cord of a client’s continuous passive motion (CPM) device.
Which of the following actions should the nurse take first?
A. Report the defect to the equipment maintenance staff.
Reporting the defect to the equipment maintenance staff is essential,but it's not the immediate priority.The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others. Delaying the removal of the device could lead to electrical shock,fire,or other serious consequences. Therefore,removing the device from the room takes precedence over reporting the defect.
B. Remove the device from the room.
Removing the device from the room is the most appropriate first action because it: Eliminates the immediate safety hazard. Prevents potential harm to the client and others. Protects the device from further damage. Ensures the safety of the environment. Demonstrates the nurse's prioritization of patient safety.
C. Initiate a requisition for a replacement CPM device.
Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment. However,it's not the first action because it doesn't address the immediate safety concern. The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.
D. Ensure the device inspection sticker is current.
Ensuring the device inspection sticker is current is a vital part of equipment maintenance. However,it's not relevant to the immediate safety issue of the frayed cord. The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment. The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.
Full Explanation
The correct answer is b. Remove the device from the room.
Choice A rationale:
- Reporting the defect to the equipment maintenance staff is essential, but it's not the immediate priority. The primary concern is to eliminate the safety hazard posed by the frayed cord to prevent potential harm to the client and others.
- Delaying the removal of the device could lead to electrical shock, fire, or other serious consequences.
- Therefore, removing the device from the room takes precedence over reporting the defect.
Choice B rationale:
- Removing the device from the room is the most appropriate first action because it:
- Eliminates the immediate safety hazard.
- Prevents potential harm to the client and others.
- Protects the device from further damage.
- Ensures the safety of the environment.
- Demonstrates the nurse's prioritization of patient safety.
Choice C rationale:
- Initiating a requisition for a replacement CPM device is necessary to ensure the client's continued treatment.
- However, it's not the first action because it doesn't address the immediate safety concern.
- The nurse should first remove the faulty device and then initiate the process for obtaining a replacement.
Choice D rationale:
- Ensuring the device inspection sticker is current is a vital part of equipment maintenance.
- However, it's not relevant to the immediate safety issue of the frayed cord.
- The presence of a current inspection sticker doesn't guarantee the device's safety or functionality at that moment.
- The nurse must prioritize removing the hazard and then follow up with appropriate documentation and reporting.