a nurse is caring for a client who is in labor and receiving iv opioid analgesics which of the following actions should the nurse take a nurse is caring for a client who is in labor and receiving iv opioid analgesics which of the following actions should the nurse take
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Nursing Elites

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ATI Pharmacology

1. A client in labor is receiving IV Opioid analgesics. Which of the following actions should the nurse take?

Correct answer: B

Rationale: When a client is receiving IV Opioid analgesics during labor, the nurse should offer oral hygiene every 2 hours. Opioid analgesics can cause adverse effects like dry mouth, nausea, and vomiting. Providing oral hygiene care helps alleviate these symptoms and maintains the client's comfort and well-being during labor. Instructing the client to self-ambulate every 2 hours is not appropriate during labor as mobility may be limited. Anticipating medication administration 2 hours prior to delivery is not necessary as the timing of medication administration should be based on the client's needs and the progress of labor. Monitoring fetal heart rate every 2 hours is important during labor, but it is not specifically related to the client receiving IV Opioid analgesics.

2. During operation, who manages the lighting, noise, temperature and other factors in the operating room suite?

Correct answer: C: Circulating Nurse

Rationale: In an operating room, the circulating nurse is responsible for managing environmental factors such as lighting, noise, and temperature. This role includes ensuring the comfort and safety of the patient, as well as the efficiency of the team. While the Nurse Supervisor, Surgeon, and Scrub Nurse also have crucial roles during an operation, they do not directly manage the environmental conditions of the operating room. The rationale provided does not directly address the question asked, and appears to relate more to the broader role of nursing in patient care.

3. Milk and other dairy products are preferred sources of calcium because lactose enhances calcium absorption.

Correct answer: A

Rationale: Both the statement and the reason are correct and related. Milk and other dairy products are indeed preferred sources of calcium because they supply most of the available calcium. Additionally, lactose present in dairy products enhances calcium absorption, making them even more efficient sources of this essential mineral. The statement correctly identifies dairy products as preferred sources of calcium, and the reason explains how lactose contributes to better calcium absorption. The other choices are incorrect as they do not accurately assess the relationship between lactose, calcium absorption, and the preference for dairy products as sources of calcium.

4. A client has a new prescription for levothyroxine. Which of the following findings should the nurse monitor for as a potential adverse effect of the medication?

Correct answer: A

Rationale: Corrected Rationale: An increased heart rate is a common adverse effect of levothyroxine due to its role in boosting metabolism. Choice B, weight loss, is actually a therapeutic effect of levothyroxine as it helps in managing hypothyroidism by increasing the metabolic rate. Hyperthermia (Choice C) is not a typical adverse effect of levothyroxine. Decreased deep-tendon reflexes (Choice D) are not associated with levothyroxine use.

5. When interviewing a distressed client who was fired after 15 years of loyal employment, which of the following questions would best assist in determining the client's appraisal of the situation? Select all that apply.

Correct answer: B

Rationale: The question 'Have you ever experienced a similar stressful situation?' is the most appropriate as it assesses the client's coping resources and encourages reflection on past experiences. This question can help the client consider alternative ways to deal with stress. Asking about the cause of the stressful situation may provide insight into the current situation but does not directly assess coping abilities. Inquiring about blame does not focus on coping strategies but may encourage negative thinking and a sense of victimization. Questioning why the client was fired is a nontherapeutic approach that can hinder communication by putting the client on the defensive.

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