Nursing Elites

1. A client is receiving morphine for postoperative pain. What is the nurse's priority assessment?

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

Correct answer: A

Rationale: The correct answer is to monitor the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to detect this potential side effect early. Monitoring the client's level of consciousness (Choice B) is important but comes after ensuring adequate breathing. Assessing the client's pain level (Choice C) is essential but not the priority when dealing with the side effects of morphine. Monitoring the client's blood pressure (Choice D) is also important but not the priority assessment when the focus is on respiratory depression.

2. An elderly client reports new-onset confusion, nausea, dysuria, and urgency. What action should the nurse take first?

• A. Initiate intravenous fluids
• B. Obtain a clean-catch midstream urine specimen
• C. Administer antibiotics
• D. Start a Foley catheter to obtain a sterile sample

Correct answer: B

Rationale: The correct first action for the nurse to take in this scenario is to obtain a clean-catch midstream urine specimen. The client's symptoms of confusion, nausea, dysuria, and urgency are suggestive of a urinary tract infection (UTI). To confirm the diagnosis and identify the causative organism, a urine specimen should be collected before initiating any treatment. Initiating intravenous fluids (Choice A) may be necessary later based on the client's condition but is not the initial priority. Administering antibiotics (Choice C) should be done after confirming the diagnosis through urine culture. Starting a Foley catheter (Choice D) to obtain a sterile sample is more invasive and should not be the first step in the assessment and management of a suspected UTI.

3. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

4. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to

• A. Exercise doing weight-bearing activities
• B. Exercise to reduce weight
• C. Avoid exercise activities that increase the risk of fracture
• D. Exercise to strengthen muscles and thereby protect bones

Correct answer: A

Rationale: Weight-bearing exercises are crucial in managing osteoporosis as they help strengthen bones. Choice A is the correct answer because weight-bearing activities, such as walking, dancing, or weight training, help stimulate bone formation and strengthen bones, which is essential in managing osteoporosis. Choice B is incorrect as the primary focus should be on the type of exercise rather than weight reduction. Choice C is incorrect because avoiding exercise altogether can lead to further bone density loss, and it is important to engage in safe weight-bearing activities. Choice D is incorrect as the primary goal of exercise in osteoporosis is to improve bone density through weight-bearing activities.

5. A client with heart failure is receiving furosemide. What assessment finding indicates the medication is effective?

• A. Increased urine output and weight loss.
• B. Increased heart rate and blood pressure.
• C. Decreased edema and improved peripheral pulses.
• D. Decreased shortness of breath and clear lung sounds.

Correct answer: C

Rationale: The correct answer is C: 'Decreased edema and improved peripheral pulses.' In a client with heart failure, furosemide is a diuretic that helps reduce fluid overload. Therefore, a decrease in edema (swelling due to fluid retention) and improved peripheral pulses (indicating better circulation) are signs that the medication is effective. Choices A, B, and D are incorrect. Increased urine output and weight loss (Choice A) may indicate the diuretic effect of furosemide but do not specifically reflect its effectiveness in heart failure. Increased heart rate and blood pressure (Choice B) are not desired effects of furosemide and may suggest adverse reactions. Decreased shortness of breath and clear lung sounds (Choice D) are related to improved respiratory status and may not directly reflect the effectiveness of furosemide in addressing fluid overload.

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