COMPLETE QUESTIONS AND ANSWERS
ALREADY PASSED
◉ Nursing Diagnosis
The client states the pain level in his right foot is 8 on a scale of 1 to
10. He says he has been favoring his foot by staying in bed the past
week.
Answer:
◉ Client was prescribed morphine IV 0.05mg/kg/dose now and
every 2 hours as needed for moderate to severe pain. Morphine is
available in parenteral dose of 2mg/mL. How much medication
should the nurse draw up for administration? (Patient weighs 140
lbs on admission). (Enter the numerical value only. If rounding is
necessary, round to the nearest tenth)
Answer: 2.2 lbs in a kilogram
140lbs /2.2kg = 63kg
63kg x 0.05 mg = 3.15 mg
3.15mg /2 mL = 1.575 mL rounded to nearest tenth = 1.6mL
◉ Before giving the initial dose of pain medication or antibiotic,
which action should the nurse take first?
,1. Ask the client what liquid he would like to drink to swallow the
pill.
2. Teach the client the side effects of the medication.
3. Ask the client if he is aware of any allergies to medications.
4. Instruct the client to sit upright to swallow the medication.
Answer: 3. Ask the client if he is aware of any allergies to
medications.
Rationale:
1. While this action should be taken, another action should be taken
first.
2. Client teaching is important, but it does not have the most
immediate priority.
3. This action should be taken first since this is the initial dose of a
new medication. It is important to verify any allergies. Clients
sometimes recall additional allergies after the initial admission
history has been taken.
4. This instruction is important, but it does not have the highest
priority.
◉ When the client's foot pain is controlled, which nursing diagnosis
should take priority ?
1. Risk for caregiver role strain.
2. Risk for social isolation.
, 3. Impaired physical ability
4. Imbalanced nutrition: more than body requirements.
Answer: 3. Impaired physical ability
Rationale:
1. Although this risk exists for the client's wife (and could affect the
client's care), it is not the priority diagnosis.
2. Social isolation can occur, but it is not the priority diagnosis.
3. The client's limited activities support this nursing diagnosis.
Improving mobility is a nursing priority to prevent the many
potential complications of immobility.
4. There is no evidence presented to support this diagnosis.
◉ Which goal is correct for the client's diagnosis of impaired
physical mobility?
1. The client will transfer to the chair with assist of one person.
2. The nurse will reposition the client every hour while the client is
awake.
3. The client will sit in the chair for each meal beginning on the day
of admission.
4. The nurse will assist the client to ambulate in the hall by the
second hospital day.
Answer: 3. The client will sit in the chair for each meal beginning on
the day of admission