Correct Answer: B

Rationale: While it is important to monitor bowel movements, especially since opioids like morphine can cause constipation, this is not the immediate priority. Opioid-induced constipation is a common side effect due to decreased gastrointestinal motility. However, it does not pose an immediate life-threatening risk compared to respiratory depression. A respiratory rate of 7 breaths per minute is significantly below the normal range for adults, which is typically 12-20 breaths per minute. This indicates severe respiratory depression, a known and potentially fatal side effect of morphine. Immediate intervention is required to ensure the patient's airway is maintained and to prevent respiratory arrest. Although the client reporting a pain level of 8 out of 10 indicates that the pain is not adequately controlled, this is not the most urgent concern compared to respiratory depression. Pain management is crucial, but ensuring the patient's respiratory function takes precedence. A distended bladder can be a side effect of morphine due to urinary retention. While this needs to be addressed to prevent discomfort and potential complications, it is not as critical as managing a severely low respiratory rate.

Correct Answer: A,B,C,D,E

Rationale: Inspection (
A) comes first to observe visually, followed by auscultation (
B) to avoid altering bowel sounds, then percussion (
C) to assess underlying structures, light palpation (
D) to check tenderness, and deep palpation (E) to assess deeper structures like the aorta.

Correct Answer: B

Rationale: Limiting the session to 1 hour is a practical approach when teaching older adults. Research indicates that older adults may have shorter attention spans and may become fatigued more quickly than younger individuals. However, providing a distraction-free environment is more critical for effective learning. Providing an environment with minimal distractions is crucial for effective learning, especially for older adults. Distractions such as noise, poor lighting, and uncomfortable seating can hinder concentration and reduce the effectiveness of the educational program. By creating a calm and focused environment, the nurse can help older adults concentrate better on the material being taught. Presenting the information at a 10th-grade reading level may be too complex for some older adults with varying literacy levels. A lower reading level (e.g., 6th-8th grade) is often recommended for health education to ensure accessibility. Using brightly colored paper can enhance visibility and engagement, especially for those with visual impairments, but it’s less impactful than minimizing distractions for overall comprehension.

Correct Answer: B,C,D

Rationale: When providing client education about the medication, the nurse focuses on informing the client about the purpose, dosage, and potential side effects of the medication. This step is crucial for ensuring that the client understands their treatment plan and can adhere to it properly. However, this is not the appropriate time to compare the medication administration record (MAR) against the medication container. The comparison should be done during the actual medication administration process to prevent errors. At the client's bedside before administering the medication, the nurse should compare the MAR against the medication container. This step is part of the 'three checks' process, which helps ensure that the correct medication is given to the right patient at the right time. By verifying the medication at the bedside, the nurse can catch any discrepancies and prevent potential medication errors. Before selecting the medication container, the nurse should compare the MAR against the medication container. This is the first of the 'three checks' and is essential for ensuring that the correct medication is selected from the storage area. This step helps prevent errors that could occur if the wrong medication is chosen. While removing medication from the container, the nurse should again compare the MAR against the medication container. This is the second of the 'three checks' and serves as an additional safeguard to ensure that the correct medication is being prepared for administration. This step helps catch any errors that might have been missed during the initial selection. When documenting the medication administration, the nurse records the details of the medication given, including the time, dosage, and any observations. While accurate documentation is crucial for maintaining a complete medical record, this is not the appropriate time to compare the MAR against the medication container. The comparison should be done during the medication administration process to ensure accuracy.

Correct Answer: D

Rationale: Documenting the indications for using wrist restraints is an important step in the process, but it is not the first action the nurse should take. Documentation ensures that there is a clear rationale for the use of restraints and helps in maintaining legal and ethical standards. However, before documenting, the nurse must explore and attempt less restrictive alternatives to ensure that restraints are truly necessary. Obtaining a prescription for restraints from the provider is a crucial step, as restraints should only be used with a valid order from a healthcare provider. This ensures that the use of restraints is medically justified and that the provider is aware of the client's condition. However, before seeking a prescription, the nurse must first attempt less restrictive alternatives to manage the client's behavior. Explaining the procedure to the client and their family is an important step in obtaining informed consent and maintaining transparency. However, it should be done after the nurse has determined that less restrictive alternatives are not effective and that restraints are necessary. Attempting less restrictive alternatives is the first action the nurse must take. This approach aligns with ethical and legal guidelines that emphasize the use of the least restrictive measures to ensure the client's safety. Alternatives may include verbal de-escalation, environmental modifications, or the use of less restrictive devices. Only if these measures fail should the nurse consider using restraints.