a nurse is caring for a client who is receiving morphine sulfate via a patient controlled analgesia pca pump which action is most important for the nu
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Nursing Elites

HESI RN

HESI RN CAT Exit Exam 1

1. A nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?

Correct answer: A

Rationale: When a client is receiving opioids like morphine sulfate via a PCA pump, the most critical action for the nurse to implement is to monitor the client's respiratory status. Opioids can cause respiratory depression, which can be life-threatening. Monitoring respiratory status allows for early detection of any signs of respiratory compromise. Teaching the client how to use the PCA pump, evaluating pain level, and assessing pain level are important aspects of care but ensuring the client's safety by monitoring respiratory status takes precedence due to the potential risks associated with opioid administration.

2. What instruction is most important for the nurse to provide a female client who has just been diagnosed with trichomoniasis?

Correct answer: B

Rationale: The most important instruction for a female client diagnosed with trichomoniasis is to treat sexual partner(s) concurrently. This is crucial to prevent reinfection and the spread of the infection. Choice A, avoiding douching, is generally recommended for vaginal health but is not the most critical instruction in this case. Choice C, avoiding moist washcloths when bathing, is not directly related to the transmission or treatment of trichomoniasis. Choice D, postponing pregnancy until the infection is treated, is important but treating sexual partners concurrently takes precedence to prevent reinfection.

3. A client who is 32-weeks pregnant is diagnosed with partial placenta previa. Which instruction should the nurse include in this client’s teaching plan?

Correct answer: C

Rationale: Refraining from sexual intercourse helps prevent complications with partial placenta previa.

4. A male client with hypertension tells the nurse that he is going to take ginseng to increase his stamina. What information should the nurse provide this client?

Correct answer: D

Rationale: The correct answer is D: "Ginseng can increase blood pressure, which is a concern for clients with hypertension." Choice A is incorrect because ginseng does not typically decrease the effectiveness of blood pressure medication. Choice B is incorrect as stopping ginseng while on blood pressure medication may not be necessary. Choice C is not the most direct concern related to ginseng use in a hypertensive client, making it less relevant than the correct answer.

5. The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?

Correct answer: A

Rationale: The vastus lateralis is the preferred site for IM injections in infants due to muscle development. In infants under 1 year old, the vastus lateralis muscle in the thigh is often used for IM injections due to its size and development. The deltoid muscle is typically used for adults, and the ventrogluteal and dorsogluteal sites are more commonly used for older children and adults. Therefore, the best choice for administering an IM injection to a 6-month-old child is the vastus lateralis.

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