Nursing Elites

1. A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?

• A. Drowsy but responsive when her name is called
• B. SaO2 94%
• C. Respiratory rate 8/min
• D. Pain level of 6 on a scale from 0 to 10

Correct answer: C

Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.

2. Which action should the nurse take to minimize the risk of medication errors?

• A. Prepare medications ahead of time to ensure they are ready.
• B. Ensure two nurses double-check medications before administration.
• C. Administer medications at the same time each day.
• D. Rely on memory to administer the correct medications.

Correct answer: B

Rationale: The correct answer is B because ensuring two nurses double-check medications before administration is a crucial step in minimizing the risk of medication errors. This practice helps in verifying the accuracy of medication orders and reducing the chances of mistakes. Choice A may not necessarily prevent errors as preparing medications ahead of time does not guarantee accuracy. Choice C, administering medications at the same time each day, is important for consistency but does not directly address the risk of errors. Choice D, relying on memory, is highly discouraged as it increases the likelihood of errors due to human forgetfulness.

3. How can dehydration be assessed in an elderly patient?

• A. Checking skin turgor on the forearm
• B. Assessing for dry mucous membranes
• C. Checking for orthostatic hypotension
• D. Measuring daily weights

Correct answer: A

Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.

4. A nurse is preparing to administer morphine sulfate to a client. What should the nurse assess before administration?

• A. Assess for pain relief.
• B. Monitor for respiratory depression.
• C. Assess the infusion site for complications.
• D. Increase the dosage if the client reports more pain.

Correct answer: B

Rationale: Correct answer: Before administering morphine sulfate, the nurse should monitor for respiratory depression as it is a significant side effect of this medication. Assessing for pain relief (Choice A) is important but not a pre-administration assessment. Checking the infusion site for complications (Choice C) is relevant for IV medications, not specifically for morphine sulfate. Increasing the dosage if the client reports more pain (Choice D) is not appropriate without further assessment and medical orders.

5. A client asks about becoming an organ donor. What information should the nurse provide?

• A. The process should be discussed with family first.
• B. The organ donation process should begin immediately.
• C. Organ donation can proceed even if the family disagrees.
• D. Donor cards must be signed in the presence of a witness.

Correct answer: D

Rationale: The correct answer is D. For organ donation to be legally valid, the donor must sign consent documents in the presence of a witness. Choice A is incorrect because while discussing with family is important, it is not a legal requirement for organ donation. Choice B is incorrect as the organ donation process involves various steps and procedures that cannot begin immediately. Choice C is incorrect because organ donation typically requires consent and cooperation from the family if the donor is unable to provide consent.

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