a nurse is assessing a client who is receiving morphine via a patient controlled analgesia pca pump which of the following findings should the nurse r

ATI RN

ATI RN Comprehensive Exit Exam

1. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the nurse report to the provider?

A. Respiratory rate of 20/min
B. Oxygen saturation of 93%
C. Pain level of 2 on a scale of 0 to 10
D. Blood pressure of 110/70 mm Hg

Correct answer: D

Rationale: The correct answer is D because a blood pressure drop or other signs of morphine overdose should be reported, especially when using a PCA pump. Choices A, B, and C are within normal limits and do not indicate an immediate concern related to morphine administration.

2. A client who is at 28 weeks of gestation is being taught by a nurse about managing heartburn. Which of the following instructions should the nurse include?

A. Eat small, frequent meals.
B. Drink a glass of milk with each meal.
C. Lie down after meals.
D. Drink plenty of fluids with meals.

Correct answer: A

Rationale: The correct instruction for managing heartburn during pregnancy is to eat small, frequent meals. This helps prevent heartburn by reducing gastric distention. Option B, drinking a glass of milk with each meal, may exacerbate heartburn in some individuals due to its fat content. Option C, lying down after meals, can worsen heartburn as it allows stomach acid to flow back into the esophagus. Option D, drinking plenty of fluids with meals, can also contribute to heartburn by distending the stomach. Therefore, the best advice for managing heartburn during pregnancy is to eat small, frequent meals.

3. What is the first action to take for a patient experiencing a seizure?

A. Administer anticonvulsant medication
B. Protect the patient's head
C. Insert an oral airway
D. Restrain the patient

Correct answer: B

Rationale: The first action a nurse should take for a patient experiencing a seizure is to protect the patient's head. This is crucial to prevent head injuries during the seizure. Administering anticonvulsant medication may be necessary but is not the first action. Inserting an oral airway may cause injury as the patient may bite down during a seizure. Restraint is not recommended as it can lead to further harm.

4. Which lab value should be monitored in patients receiving furosemide?

A. Monitor potassium levels
B. Monitor sodium levels
C. Monitor calcium levels
D. Monitor glucose levels

Correct answer: A

Rationale: The correct answer is to monitor potassium levels in patients receiving furosemide. Furosemide is a loop diuretic that can lead to potassium loss in the urine, potentially causing hypokalemia. Monitoring potassium levels is crucial to prevent complications associated with low potassium levels, such as cardiac arrhythmias. Monitoring sodium levels (choice B) is not typically necessary with furosemide use, as it primarily affects potassium levels. Calcium levels (choice C) and glucose levels (choice D) are not directly impacted by furosemide and require monitoring for other conditions or medications.

5. How should a healthcare professional monitor a patient with a central line for infection?

A. Monitor the dressing site daily
B. Check for redness and swelling
C. Monitor for fever
D. Flush the central line

Correct answer: A

Rationale: Monitoring the dressing site daily is crucial for detecting early signs of infection in patients with central lines. Checking for redness and swelling (choice B) is important but may indicate a more advanced stage of infection. Monitoring for fever (choice C) can also be a sign of infection, but it is a later manifestation. Flushing the central line (choice D) is necessary for maintaining patency but does not directly monitor for infection.