a nurse is providing teaching to a newly licensed nurse about administering morphine via iv bolus to a client which of the following information shoul
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ATI LPN

PN ATI Capstone Proctored Comprehensive Assessment 2020 A

1. A nurse is providing teaching to a newly licensed nurse about administering morphine via IV bolus to a client. Which of the following information should the nurse include in the teaching?

Correct answer: A

Rationale: The correct answer is A because respiratory depression is a significant risk when administering morphine, and it can occur within 7 minutes after administration. This information is crucial for the nurse to recognize and respond promptly. Choice B is incorrect because the peak effect of morphine via IV bolus is typically reached within a few minutes, not specifically 10 minutes. Choice C is incorrect because withholding morphine based solely on a respiratory rate less than 16/min may not be appropriate without considering other factors such as pain level, oxygen saturation, and overall respiratory status. Choice D is incorrect because administering morphine over 2 minutes may not prevent respiratory depression if it occurs rapidly after administration. Nurses should be vigilant for signs of respiratory depression regardless of the administration duration.

2. A nurse is reviewing laboratory values for a client who reports fatigue and cold intolerance. The client has an increased thyroid stimulating hormone (TSH) level and a decreased total T3 and T4 level. The nurse should anticipate a prescription for which of the following medications?

Correct answer: C

Rationale: Levothyroxine is the correct answer. In this scenario, the client's elevated TSH and decreased T3 and T4 levels indicate hypothyroidism, a condition where the thyroid gland does not produce enough hormones. Levothyroxine is a synthetic form of thyroid hormone that is used to replace or supplement the body's naturally produced thyroid hormones. Methimazole and Propylthiouracil are used to treat hyperthyroidism by reducing the production of thyroid hormones. Somatropin is a growth hormone used to treat growth hormone deficiency and other conditions unrelated to thyroid disorders.

3. A nurse is providing teaching to a client who has cirrhosis and a new prescription for lactulose. The nurse should instruct the client that lactulose has which of the following therapeutic effects?

Correct answer: D

Rationale: The correct answer is D: Reduces ammonia levels. Lactulose is used to reduce blood ammonia levels in clients with hepatic encephalopathy. Options A, B, and C are incorrect because lactulose does not have the therapeutic effect of increasing blood pressure, preventing esophageal bleeding, or decreasing heart rate.

4. A nurse is providing teaching to a client who has a urinary tract infection and new prescriptions for phenazopyridine and ciprofloxacin. Which of the following statements by the client indicates the need for further teaching?

Correct answer: D

Rationale: Phenazopyridine can turn the urine orange, which is a normal side effect and not a cause for alarm. The client's statement about notifying the provider immediately if their urine turns orange indicates a need for further teaching because it shows a misunderstanding of the medication's side effects. Choices A, B, and C demonstrate a good understanding of the prescribed medications and their effects, indicating the client has grasped the teaching provided on those aspects.

5. A nurse is reviewing the laboratory values for a client who is receiving a continuous IV heparin infusion and has an aPTT of 90 seconds. Which of the following actions should the nurse prepare to take?

Correct answer: B

Rationale: An aPTT of 90 seconds is elevated, indicating a risk of bleeding due to excessive anticoagulation. The appropriate action is to reduce the infusion rate of heparin to prevent further complications. Administering vitamin K is not indicated for an elevated aPTT due to heparin therapy. Giving the client a low-dose aspirin can further increase the risk of bleeding when combined with heparin. Requesting an INR is not necessary for monitoring heparin therapy; aPTT is the more specific test for assessing heparin's therapeutic effect. Therefore, the correct action for the nurse to prepare to take is to reduce the infusion rate of heparin.

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