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. A client is diagnosed with pulmonary embolism and is to be treated with streptokinase (Streptase). A nurse would report which priority data collection finding to the registered nurse before initiating this therapy?

• A. Adventitious breath sounds
• B. Temperature of 99.4°F orally
• C. Blood pressure of 198/110 mm Hg
• D. Respiratory rate of 28 breaths/min

Correct answer: C

Rationale: The correct answer is C. Streptokinase therapy is contraindicated in severe uncontrolled hypertension due to the risk of cerebral hemorrhage. A blood pressure of 198/110 mm Hg indicates severe hypertension, which needs to be addressed before initiating streptokinase to prevent potential complications.

3. The client has a PRN prescription for ondansetron (Zofran). For which condition should this medication be administered to the postoperative client?

• A. Paralytic ileus
• B. Incisional pain
• C. Urinary retention
• D. Nausea and vomiting

Correct answer: D

Rationale: Ondansetron, also known as Zofran, is an antiemetic medication primarily used to treat nausea and vomiting. In the postoperative setting, it is commonly administered to manage postoperative nausea and vomiting, which are frequent occurrences after surgery. Ondansetron works by blocking serotonin, a natural substance in the body that can trigger nausea and vomiting. It is also utilized to manage chemotherapy-induced nausea and vomiting. Therefore, the correct condition for which ondansetron should be administered to the postoperative client is nausea and vomiting.

4. A postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. After administration of the medication, the nurse checks the client for:

• A. Pupillary changes
• B. Scattered lung wheezes
• C. Sudden increase in pain
• D. Sudden episodes of diarrhea

Correct answer: C

Rationale: Naloxone hydrochloride is an antidote to opioids and may be administered to postoperative clients to address respiratory depression. This medication can also reverse the effects of analgesics, potentially leading to a sudden increase in pain. Therefore, the nurse must assess the client for any unexpected rise in pain levels after naloxone administration. Choices A, B, and D are incorrect because pupillary changes, scattered lung wheezes, and sudden episodes of diarrhea are not typically associated with naloxone administration for respiratory depression.

5. A client with hyperparathyroidism has a serum calcium level of 13 mg/dL. Which medication should be prepared to administer as prescribed to the client?

• A. Calcium chloride
• B. Calcium gluconate
• C. Calcitonin (Miacalcin)
• D. Large doses of vitamin D

Correct answer: C

Rationale: The normal serum calcium level ranges from 8.6 to 10.0 mg/dL. In hypercalcemia, as seen in this client, Calcitonin (Miacalcin) is used to decrease plasma calcium levels by inhibiting bone resorption. Calcium gluconate and calcium chloride are typically used for hypocalcemia, not hypercalcemia. Large doses of vitamin D should be avoided in hypercalcemia as they can exacerbate hypercalcemia by increasing calcium absorption from the intestines.

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