1. When administering IV morphine every 3-4 hrs PRN post op. What are the nurses'

interventions?

● Administer drug over 5 mins

● Tell the patient to ask for assistance getting out of bed

Rationale–Morphine is an opioid agonist used to provide analgesia in clients with moderate to

severe pain. When given intravenously, it has a rapid onset of action and should be given over 5

minutes. Pain assessment should be performed before the administration of morphine and at

20 minutes after IV administration. During administration, the level of consciousness and vital

signs should be assessed periodically; when the respiratory rate <10>

assess sedation. Morphine can cause sedation, so clients should be instructed about potential

drowsiness or dizziness and should call for assistance when getting out of bed or ambulating.

Clients should be advised to change position cautiously to minimize the risk of orthostatic

 hypotension. Clients who are on prolonged bed rest or who are immobilized should breathe

deeply, cough, and turn to prevent atelectasis. Atelectasis is a concern in postoperative clients

who may avoid deep breathing due to pain.

2. A client with ulcercolitisis is scheduled for a lower GI endoscopy that shows ulcerations

and stricirtions. What is true about this disorder?

● Anemia is a common finding

Rationale– Ulcerative colitis (UC) is a disorder of inflammation of the colonic mucosa.

 Ulcerations and structures are characteristic. Onset is usually gradual. Diagnostic tests include

CBC (complete blood count), erythrocyte sedimentation rate, endoscopy, and stool culture.

Anemia occurs in UC due to loss of blood from friable mucosa in the stool. Abdominal rigidity

does not occur as a symptom in UC, although abdominal tenderness is usually seen. Disease is

limited to the colon and rectum in UC. Other symptoms include tenesmus, fever, loose or watery

stools with pus or mucus, crampy abdominal pain, anorexia, fluid and electrolyte imbalances,

and malnutrition.

3. A charge nurse on the med- surg unit was just told that a disaster proctol is being

implemented. What action should the nurse take?

● Make a list of patients who can be discharged

Rationale- Following the initiation of disaster protocol, the charge nurse should identify that

clients who are stable can be discharged to allow clients who are harmed by the disaster to be

admitted. The charge nurse should make a list of potential client dismissals and work

collaboratively with providers to obtain discharge prescriptions. Clients Who Can Be Potentially

Discharged Following a Disaster • Ambulatory clients who were admitted previously for

observation • Ambulatory clients who admitted for undergoing diagnostic evaluation • Clients

who are stable and can be cared for at home by family or support services • Clients who are

stable and can be transferred to another facility • Clients who have remained stable for a

minimum of 3 days.

4. The nurse is performing an assessment of a client with cholesteatoma where the incus is

affected. At what mark on the drawing of the ear is the client's condition located?

** Where the H is located**