a nurse is caring for a client receiving morphine which of the following should the nurse monitor
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Nursing Elites

ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A with NGN

1. A client is receiving morphine. Which of the following should the nurse monitor?

Correct answer: B

Rationale: Corrected Rationale: When a client is receiving morphine, monitoring the respiratory rate is crucial because morphine can cause respiratory depression. Therefore, it is essential for the nurse to assess the client's breathing to detect any signs of respiratory distress. Choices A, C, and D are incorrect because morphine primarily affects the respiratory system, not the liver function, blood glucose levels, or bowel sounds.

2. A nurse is teaching a client about nonpharmacological pain management techniques. Which statement about hypnosis is appropriate?

Correct answer: A

Rationale: The correct answer is A: "Hypnosis promotes increased control of pain perception during labor." Hypnosis can be effectively utilized during labor to help individuals enhance their control over how they perceive pain. Choice B is incorrect because hypnosis does not primarily use therapeutic touch to reduce anxiety. Choice C is incorrect as hypnosis is not primarily focused on biofeedback as a relaxation technique. Choice D is incorrect because hypnosis does not provide direct instructions to minimize pain but rather helps individuals gain control over their pain perception.

3. A nurse is providing teaching about breastfeeding to a client who is postpartum. Which of the following instructions should the nurse include?

Correct answer: C

Rationale: The correct answer is C: 'Ensure your newborn has at least six wet diapers per day.' Six or more wet diapers per day is an indicator that the newborn is receiving adequate breast milk, making this an important part of breastfeeding education. Choice A is incorrect because washing nipples with soap after each feeding can lead to dryness and cracking. Choice B is incorrect as babies should nurse on demand rather than on a strict schedule of 5 minutes every 4 hours. Choice D is incorrect as giving water to a newborn between feedings is not recommended and can interfere with breastfeeding.

4. A nurse is providing teaching for a child who is prescribed ferrous sulfate. Which of the following instructions should the nurse include?

Correct answer: B

Rationale: The correct answer is B: 'Take with a glass of orange juice.' Ferrous sulfate should be taken with orange juice (vitamin C) to enhance the absorption of iron. Taking it with milk (choice A) is not recommended as calcium can interfere with iron absorption. Taking it at bedtime (choice C) or with meals (choice D) may lead to decreased absorption due to interactions with other food or medications.

5. A nurse is teaching the parent of a newborn about car seat safety. Which of the following statements should the nurse make?

Correct answer: A

Rationale: The correct answer is A. The car seat should remain rear-facing until the baby is at least 2 years old to ensure maximum safety in the event of a collision. This position helps protect the infant’s head, neck, and spine. Choice B is incorrect because the retainer clip should be positioned at armpit level on the baby, not over the upper part of the abdomen. Choice C is incorrect as the baby should be placed in the car seat with a slight recline, not at a 90-degree angle. Choice D is incorrect as the shoulder harness straps should be at or below the baby's shoulders, not above, to ensure proper fit and safety.

Similar Questions

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