Nursing Elites

1. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

• A. Measure the client's vital signs.
• B. Assess the client's pain level.
• C. Verify the morphine order with another nurse.
• D. Check the client's last dose of morphine.

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

2. After a renal biopsy, a client has returned to the unit. Which of the following nursing interventions is appropriate?

• A. Ambulate the client 4 hours after the procedure
• B. Maintain the client on NPO status for 24 hours
• C. Monitor vital signs
• D. Change the dressing every 8 hours

Correct answer: C

Rationale: Monitoring vital signs is crucial after a renal biopsy to promptly detect any signs of bleeding or complications. Ambulating the client 4 hours after the procedure may increase the risk of bleeding, so it is not appropriate. Maintaining the client on NPO status for 24 hours is not necessary unless specifically ordered by the healthcare provider. Changing the dressing every 8 hours is not typically indicated unless there is a specific concern or order to do so.

3. A client is recovering from gallbladder surgery performed under general anesthesia. How many times per hour should the nurse encourage the client to use the incentive spirometer?

• A. 4-5 times per hour
• B. 2-3 times per hour
• C. 6-7 times per hour
• D. 8-10 times per hour

Correct answer: A

Rationale: Encouraging the client to use the incentive spirometer 4-5 times per hour is the correct approach post-gallbladder surgery under general anesthesia. This frequency helps prevent respiratory complications, such as atelectasis, by promoting lung expansion. Choices B, C, and D suggest either too few or too many sessions per hour, which may not be optimal for the client's respiratory recovery needs. It is important to strike a balance between ensuring adequate lung expansion and not overexerting the client, which is why 4-5 times per hour is the recommended frequency.

4. A healthcare professional is admitting a client who has influenza. Which of the following types of transmission precautions should the healthcare professional initiate?

• A. Airborne
• B. Droplet
• C. Contact
• D. Protective environment

Correct answer: B

Rationale: Droplet precautions should be initiated for clients with infections that spread via droplet nuclei larger than 5 microns in diameter, such as influenza, rubella, meningococcal pneumonia, and streptococcal pharyngitis. In the case of influenza, the virus is primarily spread through respiratory droplets produced when an infected person coughs, sneezes, or talks. Airborne precautions are used for pathogens that remain infectious over long distances, typically smaller than 5 microns, like tuberculosis. Contact precautions are for diseases transmitted by direct or indirect contact, and protective environment precautions are for immunocompromised individuals to protect them from environmental pathogens.

5. A nurse is developing an individualized plan of care for a patient. Which action is important for the nurse to take?

• A. Establish goals that are measurable and realistic.
• B. Set goals that are a little beyond the capabilities of the patient.
• C. Use the nurse's own judgment and not be swayed by family desires.
• D. Explain that without taking alignment risks, there can be no progress.

Correct answer: A

Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.

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