Nursing Elites

1. A client is receiving morphine sulfate for pain management. Which assessment finding requires immediate action?

• A. Constipation
• B. Drowsiness
• C. Respiratory rate of 10 breaths per minute
• D. Nausea

Correct answer: C

Rationale: A respiratory rate of 10 breaths per minute indicates respiratory depression, a serious side effect of morphine sulfate that can lead to respiratory compromise and requires immediate intervention. Constipation, drowsiness, and nausea are common side effects of morphine but are not immediately life-threatening compared to respiratory depression. Monitoring and addressing a low respiratory rate are crucial in preventing further respiratory distress or failure.

2. Bethanechol chloride (Urecholine) is prescribed for a client with urinary retention. Which disorder would be a contraindication to the administration of this medication?

• A. Gastric atony
• B. Urinary strictures
• C. Neurogenic atony
• D. Gastroesophageal reflux

Correct answer: B

Rationale: Bethanechol chloride (Urecholine) should not be administered to clients with urinary strictures as it can contract the bladder and increase pressure within the urinary tract. In individuals with urinary strictures, this elevated pressure may lead to bladder rupture. Therefore, caution is advised when considering the use of Bethanechol chloride in clients with urinary strictures to prevent potential complications. Gastric atony, neurogenic atony, and gastroesophageal reflux are not contraindications for the administration of Bethanechol chloride for urinary retention.

3. The healthcare provider is reviewing the history and physical examination of a client who will be receiving asparaginase (Elspar), an antineoplastic agent. The healthcare provider consults with the registered nurse regarding the administration of the medication if which of the following is documented in the client's history?

• A. Pancreatitis
• B. Diabetes mellitus
• C. Myocardial infarction
• D. Chronic obstructive pulmonary disease

Correct answer: A

Rationale: Asparaginase is contraindicated in clients with a history of pancreatitis due to the risk of impairing pancreatic function and causing complications. Therefore, the healthcare provider should consult with the registered nurse to assess the client's history of pancreatitis before administering asparaginase.

4. Mafenide acetate (Sulfamylon) is prescribed for a client with a burn injury. When applying the medication, the client complains of local discomfort and burning. Which of the following is the most appropriate nursing action?

• A. Notifying the registered nurse
• B. Discontinuing the medication
• C. Informing the client that this is normal
• D. Applying a thinner film than prescribed to the burn site

Correct answer: C

Rationale: The correct action is to inform the client that local discomfort and burning are normal reactions to Mafenide acetate. This medication is used to treat burns by reducing bacteria in avascular tissues. Discontinuing the medication or applying a thinner film than prescribed is not necessary or recommended in this situation.

5. A client with angina pectoris is experiencing chest pain that radiates down the left arm. The nurse administers a sublingual nitroglycerin tablet to the client. The client's pain is unrelieved, and the nurse determines that the client needs another nitroglycerin tablet. Which of the following vital signs is most important for the nurse to check before administering the medication?

• A. Temperature
• B. Respirations
• C. Blood pressure
• D. Radial pulse rate

Correct answer: C

Rationale: The correct answer is checking the client's blood pressure (C) before administering another nitroglycerin tablet. Nitroglycerin can cause hypotension, and monitoring blood pressure is crucial to prevent a sudden drop in blood pressure, especially when giving another dose of nitroglycerin.

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