During shift report, the night nurse reports that the child who is terminally ill has developed tolerance to the morphine that the child has been receiving. The oncoming nurse realizes that the child:
1. Is physically dependent on morphine.
2. Is addicted to morphine.
3. Is showing physical signs of withdrawal.
4. Will need more medication to achieve the same effect.
4
Rationale 1: While the child may be physically dependent, this is not the meaning of tolerance.
Rationale 2: Addiction refers to a compulsive use of a substance despite harm. This is not the definition of tolerance.
Rationale 3: Withdrawal occurs when the opioid is stopped suddenly. This is not the meaning of tolerance.
Rationale 4: Tolerance occurs when the body has become accustomed to the presence of the drug in the system. When this happens, the child will need more of a drug or a stronger drug to get the same effect.
Global Rationale:
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The nurse is responsible for monitoring the feedings of the infant with hyperbilirubinemia every 2 to 3 hours around the clock. The purpose of these formula or breast feedings is to: a. prevent hyperglycemia
b. provide fluids and protein. c. decrease gastrointestinal motility. d. prevent rapid emptying of the bilirubin from the bowel.
The older adult client is receiving the third unit of packed red blood cells that have been administered in the last 8 hours. One hour into the third transfusion, a nurse observes the client to have distended neck veins in the sitting position
What is the nurse's best first ac-tion? A. Slow the infusion rate. B. Discontinue the transfusion. C. Document the observation as the only action. D. Check the type of infusing blood with the client's blood type.
Which nursing students are using the learning resource center appropriately? (Select all that apply.)
a. Student A checks out a text for home use. b. Student B obtains an article on interlibrary loans. c. Student C makes a copy of a reference article. d. Student D finds it a quiet place to study. e. Student E seeks to purchase a book. f. Student F obtains a back issue of a nursing journal. g. Student G goes there to instant message.
Which would be an acceptable community-health diagnosis?
1. Risk for Injury Related to Lack of Safe Bicycle Paths in High-Traffic Areas 2. Ineffective Family Coping Related to Lack of Time Together 3. Alterations in Nutrition Related to Use of Fast Food Restaurants 4. Ineffective Communication Related to Lack of Community Newsletter