Nursing Elites

1. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?

• A. Client reports nausea.
• B. Urinary output of 20 mL/hr.
• C. Oxygen saturation 90%.
• D. Respiratory rate 14/min.

Correct answer: C

Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.

2. What is the most effective way to prevent the spread of infection in a healthcare setting?

• A. Hand hygiene
• B. Wearing personal protective equipment
• C. Sterilizing equipment
• D. Isolating infected patients

Correct answer: A

Rationale: Hand hygiene is considered the most effective method to prevent the spread of infection in a healthcare setting. Proper hand hygiene, including washing hands with soap and water or using hand sanitizer, is crucial in reducing the transmission of pathogens from one person to another. While wearing personal protective equipment, sterilizing equipment, and isolating infected patients are also important infection control measures, they are not as universally effective as hand hygiene in preventing the spread of infections. Personal protective equipment can prevent contact with infectious materials, sterilizing equipment reduces the risk of contamination, and isolating infected patients helps prevent the spread of specific infections, but they are more targeted approaches compared to the broad and essential practice of hand hygiene.

3. A client diagnosed with dementia wanders the halls of the locked nursing unit during the day. To ensure the client's safety while walking in the halls, the nurse should do which of the following?

• A. Administer PRN haloperidol (Haldol) to decrease the need to walk
• B. Assess the client's gait for steadiness
• C. Restrain the client in a geriatric chair
• D. Administer PRN lorazepam (Ativan) to provide sedation

Correct answer: B

Rationale: Assessing the client's gait for steadiness is the most appropriate action to ensure the safety of a client with dementia while walking. This allows the nurse to identify any issues that may increase the risk of falls or accidents. Administering PRN haloperidol or lorazepam is not indicated as the first-line approach in managing wandering behavior and can have adverse effects like increased risk of falls, confusion, or oversedation. Restraint use should be avoided whenever possible, as it can lead to physical and psychological harm to the client.

4. A nurse is assessing the remote memory of an older adult client who has mild dementia. Which of the following questions should the nurse ask the client?

• A. Can you tell me who visited you today?
• B. What high school did you graduate from?
• C. Can you list your current medications?
• D. What did you have for breakfast yesterday?

Correct answer: B

Rationale: The correct answer is B: 'What high school did you graduate from?' Remote memory involves recalling past events, such as educational history, making option B the most appropriate question to assess this aspect of memory in an older adult with mild dementia. Option A pertains to recent memory. Option C focuses on short-term memory. Option D addresses recent memory as well.

5. How should a healthcare professional manage a patient with a suspected deep vein thrombosis (DVT)?

• A. Administer anticoagulants and monitor for bleeding
• B. Elevate the limb and administer pain relief
• C. Restrict mobility and apply warm compress
• D. Administer IV fluids and provide bed rest

Correct answer: A

Rationale: Corrected DVT management involves administering anticoagulants to prevent clot growth and monitoring for signs of bleeding. Elevating the limb and administering pain relief (Choice B) may help alleviate symptoms but do not address the underlying issue of preventing clot progression. Restricting mobility and applying warm compress (Choice C) could potentially dislodge the clot and worsen the condition. Administering IV fluids and providing bed rest (Choice D) are not primary interventions for managing DVT.

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