Nursing Elites

1. A client is receiving morphine for pain management. What is the most important assessment for the nurse to perform?

• A. Check the client's respiratory rate
• B. Assess the client's pain level
• C. Monitor the client's blood pressure
• D. Evaluate the client's level of consciousness

Correct answer: A

Rationale: The correct answer is to check the client's respiratory rate. Morphine can lead to respiratory depression, which makes it crucial for the nurse to monitor the client's breathing closely. Assessing the respiratory rate helps in early detection of potential respiratory depression and allows prompt intervention. While assessing pain level (choice B) is important, monitoring the respiratory status takes precedence due to the risk of respiratory depression with morphine. Monitoring blood pressure (choice C) is relevant but not as crucial as assessing respiratory status in a client receiving morphine. Evaluating the level of consciousness (choice D) is also important but does not directly address the immediate risk associated with morphine administration.

2. The nurse is caring for a client postoperatively following a hip replacement. Which intervention is most important to prevent dislocation of the prosthesis?

• A. Keep the client in a low Fowler's position
• B. Maintain hip abduction with pillows
• C. Encourage early ambulation
• D. Place the client in a prone position

Correct answer: B

Rationale: Maintaining hip abduction with pillows is crucial in preventing dislocation of the hip prosthesis postoperatively. This position helps keep the hip joint stable and reduces the risk of the prosthesis becoming displaced. Choices A, C, and D are not as effective in preventing dislocation. Keeping the client in a low Fowler's position does not provide the necessary hip support. While early ambulation is important for circulation and preventing complications, maintaining hip abduction is more specific to preventing prosthesis dislocation. Placing the client in a prone position can increase the risk of hip prosthesis dislocation due to the extreme positioning.

3. The nurse is teaching a client with diabetes about foot care. Which instruction is most important to prevent complications?

• A. Soak feet in warm water daily
• B. Apply moisturizer between the toes
• C. Wear cotton socks
• D. Inspect feet daily for cuts or sores

Correct answer: D

Rationale: The correct answer is D: Inspect feet daily for cuts or sores. Daily foot inspection is crucial for clients with diabetes to detect early signs of injury or infection. Soaking feet in warm water daily (choice A) can lead to skin maceration, making the skin more susceptible to breakdown. Applying moisturizer between the toes (choice B) can increase moisture and the risk of fungal infections. While wearing cotton socks (choice C) is beneficial for diabetic foot care, it is not as crucial as daily foot inspections to prevent complications.

4. Which intervention is most effective in preventing the spread of infection in a healthcare setting?

• A. Wearing gloves
• B. Using hand sanitizer
• C. Practicing hand hygiene
• D. Disinfecting surfaces

Correct answer: C

Rationale: Practicing hand hygiene is the most effective measure to prevent the spread of infection in healthcare settings. While wearing gloves, using hand sanitizer, and disinfecting surfaces are important infection control measures, they are not as effective as proper hand hygiene. Hand hygiene, including handwashing with soap and water or using alcohol-based hand sanitizers, is crucial in preventing the transmission of pathogens from one person to another, making it the best choice among the options provided. Wearing gloves primarily protects the wearer and is not a substitute for hand hygiene. Using hand sanitizer is helpful but may not be as effective as proper handwashing. Disinfecting surfaces is important but does not address the direct transmission of pathogens through hand contact, which hand hygiene effectively prevents.

5. A client with a diagnosis of osteoporosis is prescribed alendronate (Fosamax). What is the most important instruction the nurse should provide?

• A. Take the medication in the morning on an empty stomach.
• B. Take the medication at bedtime.
• C. Remain upright for at least 30 minutes after taking the medication.
• D. Take the medication with a full glass of water.

Correct answer: D

Rationale: The most important instruction the nurse should provide to a client prescribed alendronate (Fosamax) for osteoporosis is to take the medication with a full glass of water. This is crucial to help prevent esophageal irritation. Option A is correct as alendronate should be taken in the morning on an empty stomach. Option C is incorrect because the client should remain upright for at least 30 minutes after taking the medication, not lie down. Option B is incorrect and a duplicate of Option A.

Similar Questions