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Questions 148

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Question 1 of 5

A nurse on the orthopedics floor is asked by another nurse to witness her waste 1 mg of morphine. The nurse draws the full 2 mg dose of morphine into the syringe and tells the first nurse, 'This client does not get enough pain relief with 1 mg of morphine, so I just go ahead and give 2 mg to keep him comfortable because the doctor won't change the dose.' Which is the correct action by the first nurse?

Correct Answer: B

Rationale: Administering an unordered dose is a medication error and potential diversion. Refusing to sign and reporting ensures patient safety and accountability.

Question 2 of 5

Prior to drawing blood for blood gas analysis, the nurse conducts the modified Allen test to ensure there is adequate collateral circulation. The nurse asks the client to extend the wrist over a rolled towel and make a fist. Place the following steps (Roman numerals) in order from first to last.

Order the Items

Source Container

Ask the client to open and close the hand until the skin blanches.
Palpate the ulnar and radial pulses and apply pressure to both arteries.
Observe the hand for color.
Release the ulnar artery while maintaining pressure on the radial artery.

Correct Answer: A,B,D,C

Rationale: Modified Allen test sequence: Blanch hand (I), compress arteries (II), release ulnar artery (IV), observe color return (III) to confirm collateral circulation.

Question 3 of 5

A client has ataxia following a cerebral vascular accident. The nurse should:

Correct Answer: A

Rationale: Ataxia impairs coordination, increasing fall risk, so supervising ambulation is essential for safety.

Question 4 of 5

A client who has chosen to breastfeed tells the nurse that her nipples became very sore while she was breastfeeding her older child. Which measure will help her to avoid soreness of the nipples?

Correct Answer: B

Rationale: Breaking suction gently prevents nipple trauma, reducing the risk of soreness during breastfeeding.

Question 5 of 5

The nurse is assessing a client for tactile fremitus. Which client would most likely exhibit a decrease in tactile fremitus? A client with:

Correct Answer: A

Rationale: Emphysema causes air trapping and hyperinflation, reducing tactile fremitus due to decreased transmission of vocal vibrations through the lungs.

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