AND ANSWERS 100% CORRECT!
, A nurse prepares to collect a blood specimen from a client. Which client identifiers does
the nurse use before obtaining the sample? - ANSWER - The client's date of birth
- The client's full name
- The medical record number
A client with leukemia is admitted for blood transfusions. Which data does the nurse
recognize as increasing the client's risk of falls?
- The client reports having stress incontinence
- The client has a history of Parkinson disease.
- The client is prescribed diphenhydramine prior to the transfusion.
- The client uses a cane at home when ambulating.
- The client reports having fallen at home last week. - ANSWER - The client has a
history of Parkinson disease.
- The client is prescribed diphenhydramine prior to the transfusion.
- The client reports having fallen at home last week.
A client on the orthopedics floor after a knee replacement is prescribed a patient-
controlled analgesia (PCA) pump with morphine. Which data indicates to the nurse that
the client is experiencing an adverse response to the prescribed therapy?
Select All That Apply:
The client has a respiratory rate of 8 breaths/min.
The client reports nausea and vomiting.
The client reports pain of 9/10.
The client has a blood pressure of 140/88 mmHg.
The sleeping client is very difficult to arouse. - ANSWER - The client has a respiratory
rate of 8 breaths/min.
- The sleeping client is very difficult to arouse.
Adverse reactions to opioid medications include respiratory depression and decreased
level of consciousness. They suggest that the client has received too much medication.
If the respiratory depression is accompanied by a decreased level of consciousness,
naloxone may be prescribed. High pain rating and high blood pressure are not
associated with morphine PCA. Nausea and vomiting, along with constipation, are side
effects of morphine, not adverse reactions.
A facility uses the charting-by-exception method of documentation. When documenting
physical data findings, which client finding allows the nurse to select "within defined
limits"?
Absent bowel sounds in left lower quadrant