Nursing Elites

1. A healthcare professional is assessing a client receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the healthcare professional identify as an adverse effect of the medication?

• A. Diarrhea.
• B. Urinary retention.
• C. Hypotension.
• D. Bradycardia.

Correct answer: C

Rationale: Hypotension is a common adverse effect of morphine due to its vasodilatory properties. It can lead to a drop in blood pressure, which should be closely monitored during administration. Diarrhea (Choice A) is not a typical adverse effect of morphine. Urinary retention (Choice B) is a side effect of morphine due to its impact on the bladder muscles, but it is not classified as an adverse effect. Bradycardia (Choice D) is not a common adverse effect of morphine; instead, it tends to cause tachycardia.

2. A client is receiving furosemide for heart failure. Which of the following findings should the nurse report to the provider?

• A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
• B. Heart rate of 68/min.
• C. Potassium level of 3.8 mEq/L.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. A heart rate of 68/min is lower than expected and should be reported as it may indicate digoxin toxicity. Choices A, C, and D are within normal limits for a client receiving furosemide for heart failure and do not require immediate reporting. Weight loss may be expected due to diuretic therapy, a potassium level of 3.8 mEq/L is within the normal range, and a urine output of 60 mL/hr indicates adequate renal perfusion.

3. How should signs of infection in a post-surgical patient be assessed?

• A. Check the surgical site
• B. Check the patient's vital signs
• C. Monitor for fever
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Assessing the surgical site is crucial in identifying early signs of infection post-surgery. Changes such as redness, swelling, warmth, or drainage may indicate an infection developing. While monitoring vital signs and fever are important in infection assessment, they are general indicators and may not show localized signs at the surgical site. Checking for abnormal breath sounds is more relevant when assessing respiratory issues rather than infection at the surgical site.

4. A nurse is caring for a client who is receiving TPN. Which of the following actions should the nurse take to prevent infection?

• A. Change the TPN tubing every 72 hours.
• B. Monitor the client's blood glucose every 4 hours.
• C. Monitor the client's urine output every 8 hours.
• D. Use sterile technique when changing the central line dressing.

Correct answer: D

Rationale: The correct answer is D: 'Use sterile technique when changing the central line dressing.' When caring for a client receiving TPN, it is crucial to maintain aseptic technique to prevent infections. Changing the central line dressing with sterile technique helps reduce the risk of introducing pathogens into the client's system. Choices A, B, and C are incorrect because changing the TPN tubing every 72 hours, monitoring blood glucose, and monitoring urine output are important aspects of care but are not directly related to preventing infection in clients receiving TPN.

5. Which assessment finding is most concerning in a patient receiving morphine?

• A. Hypotension
• B. Bradycardia
• C. Respiratory depression
• D. Hypertension

Correct answer: C

Rationale: The correct answer is C, respiratory depression. When a patient is receiving morphine, respiratory depression is the most concerning side effect because it can lead to serious complications, including respiratory arrest and even death. Monitoring the patient's respiratory status is crucial to ensure early detection of any signs of respiratory depression. Choices A, B, and D are incorrect because although hypotension, bradycardia, and hypertension can occur as side effects of morphine, they are not as immediately life-threatening as respiratory depression in this context.

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