-1 HESI - Medical Surgical Nursing test Questions and Answers

-1 HESI - Medical Surgical Nursing test Questions and Answers C, D, E, F clients with poor nutrition, fatigue, and multiple chronic illnesses are at greater risk for hypothermia. Clients who smoke, consume alcohol, or have impaired peripheral circulation have a higher incidence of frostbite. The nurse is assessing a group of clients. Which clients are at greater risk for hypothermia or frostbite? (select all that apply) a. an older woman with hypertension b. a young man with a body mass index of 42 c. a young many who has just consumed six martinis d. an older man who smokes a pack of cigarettes a day e. a young woman who is anorexic f. a young woman who is diabetic D There is no evidence to support the idea that older adult clients perceive pain any differently than younger clients. The other statements are accurate regarding older clients and pain. Which statement made by a nurse represents the need for further education regarding pain management in older adult clients? a. older adults tend to report pain less often than younger adults b. older clients usually have more experience with pain than younger clients c. older adults are at greatest risk for under treated pain d. older clients have a different pain mechanism and do not feel it as much C The spectator shows signs of heat stroke, which is a medical emergency. The spectator should be transported to the ED ASAP. The nurs should take actions to lower his body temp in teh meantime by removing his shirt and sponging his body with cool water. Lowering body temp by drinking cool fluids or taking acetaminophen is not as effective in an emergency situation. The client needs to be cooled quickly and is a priority for treatment The nurse is working at a first aid booth for a spring training game on a hot day. A spectator comes in, reporting that he is not feeling well. Vital signs are temp 104.1 F, pulse 132 BPM, respirs 26 breaths/min, and blood pressure 106/66 mm Hg. He trips over his feet as the nurse leads him to a cot. What is the priory action of the nurse? a. admin tylenol 650 mg orally b. encourage rest, and reassess in 15 minutes c. sponge the victim with cool water and remove his shirt d. encourage drinking of cool water or sports drink D Potassium is a severe tissue irritant. The safest action is to discontinue the solution that contains the potassium and discontinue the IV altogether, in which case the client would need another site started. Assessing for a blood return may or may not be successful. The solution could be diluted (less potassium) and the rate could be slowed once it is determined that the needle is in the vein. The client is receiving an IV of 60 mEq of potassium chloride ina 1000 mL solution of dextrose 5% in 0.45% saline. The client states that the area around the IV site burns. What intervention does the nurse perform first? a. assess for a blood return b. notify the physician c. document the finding d. stop the IV infusion D Older adults on fixed incomes are unable to adjust their income to meet rising costs associated with meeting basic needs A nurse is caring for an older adult client who lives alone. Which economic situation presents the most serious problem for this client? a. costs of creating a living will b. stock market fluctuations c. increased provider benefits d. social security as the basis of income A Pain triggers a number of physiologic stress responses in the human body. Unrelieved pain can prolong the stress response and produce a cascade of harmful effects in all body systems. The stress response causes the endocrine system to release excessive amounts of hormones, such as cortisol, catecholamines, and glucagon. Insulin and testosterone levels decrease. Increased endocrine activity in turn initiates a number of metabolic processes, in particular, accelerated carbohydrate, protein, and fat destruction, whcih can result in weight loss, tachycardia, increased respiratory rate, shock, and even death. The immune system is also affected by pain as demonstrated by research showing a link between unrelieved pain and a higher incidence of nosocomial infections and increased tumor growth. Large tidal volumes are not associated with pain while decreased lung capacity is associated with unrelieved pain. Decreased tumo Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. prolonged stress response and a cascade of harmful effects system wide. b. decreased tumor growth and longevity c. large tidal volumes and decreased lung capacity d. decreased carbohydrate, protein, and fat destruction A Dehydration most frequently leads to poor cerebra perfusion and cerebral hypoxia, causing confusion. Applying oxygen can reduce confusion, even if perfusion is still less than optimum. Increasing the IV flow rate would increase perfusion. However, depending on the degree of dehydration, rehydrating the person too rapidly with IV fluids can lead to cerebral edema. Which intervention in a client with dehydration induced confusion is most likely to relieve the confusion? a. increasing the IV flow rate to 250 mL/hr b. applying oxygen by mask or nasal cannula c. placing the client in a high Fowler's position d. Measuring intake and output every four hours C Older adults, because they have less total body water than younger adults, are at greater risk for development of dehydration. Anyone who is cognitively impaired and cannot obtain fluids independently or cannot make his or her need for fluids known is at high risk for dehydration Which client is at greatest risk for dehydration? a. younger adult client on bedrest b. older adult client receiving hypotonic IV fluid c. older adult client with cognitive impairment d. younger adult client receiving hypertonic IV fluid B Many salt substitutes are composed of potassium chloride. Heavy use cna contribute to the development of hyperkalemia. The client should be taught to read labels and to choose a salt substitute that does not contain potassium. NSAIDs promote the retention of sodium but not potassium. A nurse is caring for several clients. Which client does the nurse assess most carefully for hyperkalemia? a. client with type 2 diabetes taking an oral anti-diabetic agent b. client with heart failure using a salt substitute c. client taking a thiazide diuretic for hypertension d. client taking non-steroidal anti-inflammatory drugs daily A Decreased renal blood flow and reduced glomerular filtration can result in slower medication excretion time, potentially leading to toxic drug accumulation. Aging results in decreased total body water and gastrointestinal motility and an increase in the ratio of adipose tissue to lean body mass, but is not related to dig toxicity. An older adult client presents with signs and symptoms related to dig toxicity. Which age related change may have contributed to this problem? a. decreased renal blood flow b. increased gastrointestinal motility c. decreased ratio of adipose tissue to lean body mass d. increased total body water D Because 1 L of water weighs 1 kg, change in body weight is a good measure of excess fluid loss or fluid retention. Weight loss greater than 0.5 lb daily is indicative of excessive fluid loss. The other statements are not indicative of practices that will prevent dehydration. A client is being treated for dehydration. Which statement made by the client indicates understanding of this condition? a. I will use a salt substitute when making and eating my meals. b. I must drink a quart of water or other liquid each day. c. I will not drink liquids after 6 PM so I won't have to get up at night. d. I will weigh myself each morning before I eat or drink. A In a client with hypokkalemia, progressive skeletal muscle weakness is associated with increasing severity of hypokalemia. The most life-threatening complication of hypokalemia is respiratory insufficiency. It is imperative for the nurse to perform a respiratory assessment first to make sure that the client is not in immediate jeopardy. Next, the nurse would call the health care provider to obtain orders for potassium replacement. The nurse notes that the handgrip of the client with hypokalemia has diminished since the previous assessment one hour ago. Which intervention by the nurse is the priority? a. assess the client's respiratory rate, rhythm, and depth b. document findings and monitor the client c. measure the client's pulse and blood pressure d. call the health care provider C 60/40 (desired/have) The physician orders Lasix (furosemide) 60 mg po every day for your patient. On hand you have Lasix 40 mg. How many tablets will you give the patient? a. 3 b. 1 c. 1 1/2 d. 2 1/5 C Clients on restricted sodium diets generally should avoid processed, smoked, and pickled foods and those with sauces and other condiments. Foods lowest in sodium include fish, poultry, and fresh produce. The chinese food likely would have soy sauce, the tomato soup is processed, and the crackers are a snack food - a category of foods often high in sodium. A client has been taught to restrict dietary sodium. Which food selection by the client indicates to the nurse that teaching has been effective? a. a grilled cheese sandwich with tomato soup b. Chinese take-out, including steamed rice c. a chicken leg, one slice of bread with butter, and steamed carrots d. slices of ham and cheese on whole grain crackers A The characteristics most common to chronic pain are psychosocial withdrawal, anger and hostility, depression, and hopelessness. The inability to concentrate is associated much more with acute pain, before any physiologic or behavioral adaptation has occurred. When a client is assessed, which behavior best indicates that he or she is experiencing changes associated with acute pain? a. inability to concentrate b. expressed hopelessness c. psychosocial withdrawal d. anger and hostility C Blood replacement therapy involves intravenous fluid administration, which inherently increases the risk for overhydration. The fact that the fluid consists of packed red blood cells greatly increases the risk, because this fluid increases the colloidal oncotic pressure of the blood, causing fluid to move from interstitial and intracellular spaces into the plasma volume. An older adult may not have sufficient cardiac or renal reserve to manage this extra fluid. A nurse is caring for several clients at risk for overhydration. The nurse assesses the older client with which finding first? A) Has had diabetes mellitus for 12 years B) Had abdominal surgery and has a nasogastric tube C) Just received 3 units of packed red blood cells D) Uses sodium-containing antacids frequently C The nurse needs to know the five rights of delegation: right task, right circumstances, right person, right communication, and right supervision. Unlicensed assistive personnel can help with feeding, but only the nurse can care plan, assess the level of consciousness, and evaluate the oxygenation of the client. The client with a stroke was admitted to a medical-surgical unit. Which tasks does the nurse delegate to the unlicensed assistive personnel? A) Assess level of consciousness. B) Evaluate the pulse oximetry reading. C) Assist the client with meals. D) Complete the nursing care plan. D The interrelated concepts to the professional role of a nurse include health promotion, leadership, technology/informatics, quality, collaboration, and communication. Adherence, culture, developmental level, family dynamics, and motivation are considered interrelated concepts to patient attributes and preference. Interrelated concepts to the professional nursing role a nurse manager would consider when addressing concerns about the quality of patient education include: A) adherence. B) developmental level. C) motivation. D) technology. D Physical agility is not a risk factor for impaired thermoregulation. The nurse educator would use this information to plan additional teaching to include medical conditions and gait disturbance as risk factors for hypothermia, because their bodies have a reduced ability to generate heat. Impaired cognition is a risk factor. Recreational or occupational exposure is a risk factor. Temperature extremes are risk factors for impaired thermoregulation. During orientation to an emergency department, the nurse educator would be concerned if the new nurse listed which of the following as a risk factor for impaired thermoregulation? A) Temperature extremes B) Occupational exposure C) Impaired cognition D) Physical agility D The application of restraints can have serious consequences. Thus, the nurse should check the client every 30 to 60 minutes, releasing the restraints every 2 hours for positioning and toileting. The other answers would not be appropriate because the client would not be assessed frequently enough, and circulation to the limbs could be compromised. Assessing every hour and releasing the restraints every 2 hours is in compliance with federal policy for monitoring clients in restraints. An older adult client is in physical restraints. Which intervention by the nurse is the priority? A) Assess the client hourly while keeping the restraints in place. B) Assess the client once each shift, releasing the restraints for feeding. C) Assess the client twice each shift while keeping the restraints in place. D) Assess the client every 30 to 60 minutes, releasing restraints every 2 hours. C Arthritis is categorized as chronic pain. With chronic pain, the body adapts by blocking the sympathetic nervous system; this normally causes tachycardia and increased blood pressure. Therefore, this client's high blood pressure and heart rate are not caused by chronic pain and may be a result of a more acute type of pain. Therefore, the best intervention is for the nurse to establish whether the client is having pain other than arthritic pain, and then to decide which intervention should be carried out. The nurse is assessing a client with a long-term history of arthritic pain. Assessment reveals a heart rate of 115 beats/min and blood pressure of 170/80 mm Hg. Which intervention will the nurse carry out first? A) Administer blood pressure medication. B) Administer a drug to lower the heart rate. C) Continue to assess for possible causes of elevated vital signs. D) Assess whether the client needs anti-arthritis medication. B Populations at highest risk for inadequate pain treatment include older adults, minorities, and those with a history of substance abuse. Nonverbal clients are very difficult to assess for pain because self-report is not possible, and the nurse needs to rely on client behaviors or surrogate reporting. The nurse is assigned to care for the following four clients who have the potential for having pain. Which client is most likely not to be treated adequately for this problem? A) Middle-aged woman with a fractured arm B) Client with expressive aphasia C) Younger adult with metastatic cancer D) Client who has undergone an appendectomy B Imagery is a form of distraction in which the client is encouraged to visualize about some pleasant or desirable feeling, sensation, or event. Behaviors that are helpful in assessing a client's capacity for imagery include being able to listen to music or other auditory stimuli. Before surgery, the nurse observes the client listening to music on the radio. Based on this observation, the nurse may try which nonpharmacologic intervention for pain relief in the postoperative setting? A) Cutaneous skin stimulation B) Imagery C) Radiofrequency ablation D) Hypnosis A The process of cultural competence consists of four interrelated constructs: cultural desire, self-awareness, cultural knowledge, and cultural skill. Cultural diversity in the context of health care refers to achieving the highest level of health care for all people by addressing societal inequalities and historical and contemporary injustices. Cultural identity is the norms, values, beliefs, and behaviors of a culture learned through families and group members. What interrelated constructs facilitate a nurse to become culturally competent? A) Cultural desire, self-awareness, cultural knowledge, and cultural skill B) Cultural desire, self-awareness, cultural knowledge, and cultural diversity C) Cultural desire, self-awareness, cultural knowledge, and cultural identity D) Cultural diversity, self-awareness, cultural skill, and cultural knowledge D Culture is an essential aspect of health care because of increasing diversity. Disability entitlements refer to defined benefits for eligible mental or physically disabled beneficiaries in relation to housing, employment, and health care. HIPAA requirements refers to the HIPAA Privacy Rule, which protects the privacy of individually identifiable health information; the HIPAA Security Rule, which sets national standards for the security of electronic protected health information; and the confidentiality provisions of the Patient Safety Rule, which protect identifiable information being used to analyze patient safety events and improve patient safety. Litigious society refers to excessively ready to go to law or initiate a lawsuit. The emphasis on understanding cultural influence on health care is important because of: A) disability entitlements. B) HIPAA requirements. C) litigious society. D) increasing global diversity. C Hypokalemia can cause postural hypotension and bilateral muscle weakness, especially in the lower extremities. Both of these increase the risk of falls. Hypokalemia does not cause edema, decreased level of consciousness, or seizures. The patient's laboratory report today indicates severe hypokalemia, and the nurse has notified the physician. Nursing assessment indicates that heart rhythm is regular. What is the most important nursing intervention for this patient now? A) Examine sacral area and patient's heels for skin breakdown due to potential edema. B) Establish seizure precautions due to potential muscle twitching, cramps, and seizures. C) Institute fall precautions due to potential postural hypotension and weak leg muscles. D) Raise bed side rails due to potential decreased level of consciousness and confusion. B D5W contains no electrolytes. Because the client is not taking any food or fluids by mouth, normal sodium excretion can lead to hyponatremia. The antibiotic, Motrin, and digoxin will not put a client at risk for hyponatremia. A nurse is assessing clients for fluid and electrolyte imbalances. Which client is at greatest risk for developing hyponatremia? A) Client taking digoxin (Lanoxin) B) Client who is NPO receiving intravenous D5W C) Client taking ibuprofen (Motrin) D) Client taking a sulfonamide antibiotic D A combined dose of 15 mg of morphine may cause severe respiratory depression in some clients. Naloxone is an opioid antagonist that can be used (intravenously) as the first intervention to reverse respiratory depression due to a morphine overdose. Then administration of oxygen may be needed if the client's oxygen saturation decreases. Intubation may occur if the client does not respond to the Narcan, and respiratory depression becomes a respiratory arrest. Naloxone may be repeated, but the pain level of the client needs to be monitored because Narcan can promote withdrawal symptoms. The nurse accidentally administers 10 mg of morphine intravenously to a client who had been given another dose of morphine, 5 mg IV, about 30 minutes earlier. What action must the nurse be prepared to take? A) Assist with intubation. B) Monitor pain level. C) Administer oxygen. D) Administer naloxone (Narcan). B Although a fixed oral intake of 1500 mL daily is good, the key to prevention of dehydration is to match all fluid losses with the same volume for fluid intake. This is especially true in warm or dry environments, or when conditions result in greater than usual fluid loss through perspiration or ventilation. Which action does the nurse teach a client to reduce the risk for dehydration? A) Avoiding the use of glycerin suppositories to manage constipation B) Maintaining a daily oral intake approximately equal to daily fluid loss C) Restricting sodium intake to no greater than 4 g/day D) Maintaining an oral intake of at least 1500 mL/day A Hypokalemia decreases cerebral function and is manifested by lethargy, confusion, inability to perform problem-solving tasks, disorientation, and coma. Normal potassium levels are 3.5 to 5.0 mEq/L. At 2.9 mEq/L, potassium is too low, and this could lead to neurologic manifestations. A client is taking furosemide (Lasix) and becomes confused. Which potassium level does the nurse correlate with this condition? A) 2.9 mEq/L B) 5.0 mEq/L C) 6.0 mEq/L D) 3.8 mEq/L A The most reliable means available for assessing core temperature is a rectal temperature, which is considered the standard of practice. An oral temperature is a common measure but not the most reliable. A temporal thermometer scan has some limitations and is not the standard. The tympanic membrane sensor could be used as a second source for temperature assessment. The most appropriate measure for a nurse to use in assessing core body temperature when there are suspected problems with thermoregulation is a(n) A) rectal thermometer. B) tympanic membrane sensor. C) temporal thermometer scan. D) oral thermometer. B Mild hypothermia is manifested by shivering, slurred speech, poor muscular coordination, and impaired cognitive abilities. Mild hypothermia may be treated with dry clothing and warm blankets. Rewarming should occur slowly by removing wet clothing and providing dry warm blankets first. Other treatments are secondary and should be used to treat moderate to severe hypothermia. A client presents to the emergency department after prolonged exposure to the cold. The client is shivering, has slurred speech, and is slow to respond to questions. Which intervention will the nurse prepare for this client FIRST? A) Continuous arteriovenous rewarming B) Dry clothing and warm blankets C) Peritoneal lavage with warmed normal saline D) Administration of warmed IV fluids B It is important for the nurse to assess respirations of the client when administering opioids because of the possibility of respiratory depression. The other interventions may or may not be necessary in the care of the client and do not focus on safety. The Joint Commission focuses on safety in health care. Which action by the nurse reflects The Joint Commission's main objective? A) Performing range-of-motion exercises on the client three times each day B) Assessing the client's respirations when administering opioids C) Delegating to the nursing assistant to give the client a complete bath daily D) Ensuring that the client is eating 100% of the meals served to him or her D Advanced age and multiple illnesses, particularly those that result in alterations in sensation, such as diabetes, predispose this client to falls. The nurse should provide assistance to the client with transfer and ambulation to prevent falls. The client should not be restrained or maintained on bedrest without adequate indication. Although family members are encouraged to visit, their presence around the clock is not necessary at this point. What is a priority nursing intervention to prevent falls for an older adult client with multiple chronic diseases? A) Requesting that a family member remain with the client to assist in ambulation B) Keeping all four siderails up while the client is in bed C) Placing the client in restraints to prevent movement without assistance D) Providing assistance to the client in getting out of the bed or chair B At times clients are unable to verbalize that they are in pain but there are indicators that the client may have acute pain such as increased heart rate, increased blood pressure, increased respirations, sweating, restlessness, and overall distress. All the other distractors could indicate clients who have the potential for being in pain, but restlessness with tachycardia is the most indicative. The nurse is caring for four clients. Which client assessment is the most indicative of having pain? A) Client stating that he is "anxious" B) Heart rate of 105 beats/min and restlessness C) Blood pressure 150/70 mm Hg and sleeping D) Postoperative client with a neck incision C The only intervention identified within the scope of nursing practice is to use sterile technique. Central line insertion, intubation, and prescription are functions of the physician. The Institute for Healthcare Improvement (IHI) identified interventions to save client lives. Which actions are within the scope of nursing practice to improve quality of care? A) Prescribe aspirin for a client who presents with an acute myocardial infarction B) Insert a central line to give intravenous fluid to a dehydrated client. C) Use sterile technique when changing dressings on a new surgical site. D) Intubate a client whose oxygen saturation is 92%. A,C,E,F No one scale has been found to be the best tool to use in pain assessment for adults with cognitive impairment. Facial expression, motor behavior, mood, socialization, and vocalization are common indicators of pain in cognitively impaired adults. In acute pain, nonverbal indicators of pain could include increased blood pressure and respirations. Which is most indicative of pain in an older client who is confused? (Select all that apply). A) Screaming B) Decreased blood pressure C) Crying D) Decreased respirations E) Facial grimace F) Restlessness D Low birth weight and poorly nourished infants (particularly premature infants) and children are at greatest risk for hypothermia. A large for gestational age infant would not be malnourished. An infant born at term is not considered at significant risk. A well nourished infant is not at significant risk. The nursery nurse identifies a newborn at significant risk for hypothermic alteration in thermoregulation because the patient is: A) large for gestational age. B) well nourished. C) born at term. D) low birth weight. C Functional ability refers to the individual's ability to perform the normal daily activities required to meet basic needs; fulfill usual roles in the family, workplace, and community; and maintain health and well-being. The other options are good; however, each option has advanced or independent activities in the context of the option. The nurse is assessing a patient's functional ability. Which activities most closely match the definition of functional ability? A) Healthy individual, college educated, travels frequently, can balance a checkbook B) Healthy individual, works out, reads well, cooks and cleans house C) Healthy individual, volunteers at church, works part time, takes care of family and house D) Healthy individual, works outside the home, uses a cane, well groomed C The Rapid Response Team (RRT) saves lives and decreases the risk for harm by providing care to clients before a respiratory or cardiac arrest occurs. Although the RRT does not replace the Code Team, which responds to client arrests, it intervenes rapidly for those who are beginning to decline clinically. It would be appropriate for the RRT to intervene when the client has experienced a 52-point drop in blood pressure. Monitoring the client's postoperative status, maintaining a postoperative flow sheet, and notifying the physician of a change in the client's status after a medication change would not be considered activities of the Rapid Response Team. Which action demonstrates that the nurse understands the purpose of the Rapid Response Team? A) Documenting all changes observed in the client and maintaining a postoperative flow sheet B) Monitoring the client for changes in postoperative status such as wound infection C) Notifying the physician of the client's change in blood pressure from 140 to 88 mm Hg systolic D) Notifying the physician of the client's increase in restlessness after medication change B,C,D,E Meperidine, propoxyphene, and codeine are not recommended for older clients because toxic metabolites may accumulate. Codeine may cause constipation as well. Methadone has an extremely long half-life (24 to 36 hours) and has a high potential for sedation and respiratory depression. Morphine is considered the gold standard and may be used in the older adult while monitoring for sedation and respiratory depression is conducted. An older client just returned from surgery and is rating pain as "8" on a 0 to 10 scale. Which medications are unsafe choices for treatment of severe pain in this older adult? (Select all that apply.) A) Morphine (Durmorph) B) Meperidine (Demerol) C) Propoxyphene (Darvocet) D) Methadone (Dolophine) E) Codeine B The ED nurse is giving recommendations to the medical-surgical floor nurse about interventions to start for the client who is being transferred. No communication is provided in the SBAR report about the situation, background, or assessment. An emergency department (ED) nurse gives report on a client who is being transferred to the medical-surgical floor. Because of an identified risk for suicide, the ED nurse suggests that the floor nurse contact a sitter and behavioral health. This statement represents which part of the SBAR hand-off? A) Situation B) Recommendation C) Background D) Assessment D Nociceptive pain refers to the normal functioning of physiological systems that leads to the perception of noxious stimuli (tissue injury) as being painful. Patients describe this type of pain as aching, cramping, or throbbing. Neuropathic pain is pathologic and results from abnormal processing of sensory input by the nervous system as a result of damage to the brain, spinal cord, or peripheral nerves. Patients describe this type of pain as burning, sharp, and shooting. Chronic pain is constant and unrelenting such as pain associated with cancer. Mixed pain syndrome is not easily recognized, is unique with multiple underlying and poorly understood mechanisms like fibromyalgia and low back pain. Understanding classifications of pain helps nurses develop a plan of care. A 62-year-old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of: A) mixed pain syndrome. B) chronic pain. C) neuropathic pain. D) nociceptive pain. D The use of fans is discouraged to promote cooling in a febrile client because the fan can disperse pathogens. The other actions are appropriate. The new nurse is caring for a client with a high temperature. Which action should the nurse perform FIRST? A) Obtaining a fan from central supply for the client's room B) Monitoring the client's temperature more often than ordered C) Sponging the client while monitoring for shivering D) Apply cool packs to the client's axillae and groin C Adults learn best when given information they can understand that is tailored to their learning styles and needs. Verbalizing an understanding is important; however, the nurse will first need to teach the patient. A patient has been newly diagnosed with hypertension. The nurse assesses the need to develop a collaborative plan of care that includes a goal of adhering to the prescribed regimen. When the nurse is planning teaching for the patient, which is the most important initial learning goal? A) The patient will demonstrate coping skills needed to manage hypertension. B) The patient will verbalize the side effects of treatment. C) The patient will select the type of learning materials they prefer. D) The patient will verbalize an understanding of the importance of following the regimen. D An understanding of the political views of family members is not a primary purpose of a family assessment. A family assessment provides the nurse with information and an understanding of family dynamics. This is important to nurses for the provision of quality health care. A family assessment provides an understanding of family development, function, and structure. When reviewing the purposes of a family assessment, the nurse educator would identify a need for further teaching if the student responded that family assessment is used to gain an understanding of the family. A) development. B) function. C) structure. D) political views. C Many clients experience some degree of respiratory depression with opioid analgesics. If the client can be aroused with minimally intrusive techniques and the rate of respiration is increased spontaneously, no further intervention is required. The client was given 15 mg of morphine IM for postsurgical pain. When the nurse checks the client for pain relief 1 hour later, the client is sleeping and has a respiratory rate of 10 breaths/min. What is the nurse's first action? A) Administering oxygen by nasal cannula B) Documenting the findings and continuing to monitor C) Arousing the client by calling his or her name D) Administering naloxone (Narcan) IV push B The physician orders Lanoxin(digoxin)0.375 mg po every day. On hand you have 0.25mg/5 mL. How many mL would you give your patient? A) 8 mL B) 7.5 mL C) 7 mL D) 5.5 mL