Nursing Elites

1. A 65-year-old female client arrives in the emergency department with shortness of breath and chest pain. The nurse accidentally administers 10 mg of morphine sulfate instead of the prescribed 4 mg. Later, the client's respiratory rate is 10 breaths/minute, oxygen saturation is 98%, and she states her pain has subsided. What is the legal status of the nurse?

• A. The nurse is guilty of negligence and will be sued.
• B. The client would not be able to prove malpractice in court.
• C. The nurse is protected by the Good Samaritan Act.
• D. The healthcare provider should have given the morphine sulfate dose.

Correct answer: B

Rationale: The correct answer is B because, in this scenario, the client would not be able to prove malpractice in court. Despite the nurse administering a higher dose of morphine than prescribed, the client's respiratory rate, oxygen saturation, and pain relief indicate that no harm resulted from the error. Therefore, the client would not have legal grounds to pursue a malpractice case against the nurse.

2. A patient with deep vein thrombosis (DVT) is prescribed warfarin. Which dietary instruction should the nurse provide?

• A. Avoid foods high in vitamin K.
• B. Increase intake of dairy products.
• C. Limit intake of citrus fruits.
• D. Avoid high-sodium foods.

Correct answer: A

Rationale: Patients on warfarin should avoid foods high in vitamin K because vitamin K can interfere with the anticoagulant effect of the medication. Warfarin works by inhibiting vitamin K-dependent clotting factors, so consuming large amounts of vitamin K-rich foods may decrease the effectiveness of the medication. Choices B, C, and D are incorrect. Increasing intake of dairy products, limiting citrus fruits, or avoiding high-sodium foods are not directly related to the mechanism of action of warfarin or its dietary considerations.

3. A client who is receiving heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. What action should the nurse take?

• A. Increase the heparin infusion rate.
• B. Notify the healthcare provider.
• C. Apply pressure to the injection site.
• D. Administer protamine sulfate.

Correct answer: B

Rationale: An activated partial thromboplastin time (aPTT) of 90 seconds is elevated, indicating a risk of bleeding. The appropriate action for the nurse is to notify the healthcare provider. Increasing the heparin infusion rate can further elevate the aPTT, leading to an increased risk of bleeding. Applying pressure to the injection site is not relevant in this situation. Administering protamine sulfate is used to reverse the effects of heparin in cases of overdose or bleeding, but it is not the initial action for an elevated aPTT.

4. A patient with epilepsy is prescribed phenytoin. What is the primary side effect the nurse should monitor for?

• A. Hypotension
• B. Gingival hyperplasia
• C. Bradycardia
• D. Hyperkalemia

Correct answer: B

Rationale: Gingival hyperplasia, or overgrowth of the gums, is a common side effect of phenytoin. Patients should maintain good oral hygiene to minimize this effect.

5. A patient with chronic heart failure is prescribed carvedilol. What is the primary purpose of this medication?

• A. Increase cardiac output
• B. Reduce fluid retention
• C. Decrease heart rate
• D. Lower blood pressure

Correct answer: C

Rationale: Carvedilol, a beta-blocker, is primarily prescribed in patients with chronic heart failure to decrease heart rate and reduce the workload on the heart. By lowering the heart rate, carvedilol helps the heart function more efficiently and improves symptoms in patients with heart failure.

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