Nursing Elites

1. A client is receiving morphine. Which of the following should the nurse monitor?

• A. Liver function
• B. Respiratory rate
• C. Blood glucose levels
• D. Bowel sounds

Correct answer: B

Rationale: Corrected Rationale: When a client is receiving morphine, monitoring the respiratory rate is crucial because morphine can cause respiratory depression. Therefore, it is essential for the nurse to assess the client's breathing to detect any signs of respiratory distress. Choices A, C, and D are incorrect because morphine primarily affects the respiratory system, not the liver function, blood glucose levels, or bowel sounds.

2. A client with a permanent spinal cord injury is scheduled for discharge. Which of the following client statements indicates that the client is coping effectively?

• A. “I would like to play wheelchair basketball. When I get stronger, I think I’ll look for a league.”
• B. “I’m glad I’ll only be in this wheelchair temporarily. I can’t wait to get back to running.”
• C. “I’m so upset that this happened to me. What did I do to deserve this, and why am I not getting better?”
• D. “I feel like I’ll never be able to do anything that I want to again. All I am is a burden to my family.”

Correct answer: A

Rationale: Choice A is the correct answer. This statement demonstrates effective coping as the client is showing acceptance of their disability and planning for the future with realistic goals. Choice B reflects denial of the permanent disability by stating that they will only be in a wheelchair temporarily. Choice C shows distress and a lack of acceptance by questioning why the injury happened and why they are not improving. Choice D indicates feelings of hopelessness and being a burden, which are not signs of effective coping.

3. A client diagnosed with pneumonia is receiving oxygen therapy at 4 L/min via nasal cannula. Which of the following interventions is most important?

• A. Encourage fluid intake.
• B. Monitor oxygen saturation levels.
• C. Change the oxygen tubing daily.
• D. Assist with frequent position changes.

Correct answer: B

Rationale: Monitoring oxygen saturation levels is the most important intervention in this scenario. It ensures that the client is receiving adequate oxygenation, which is crucial for a client with pneumonia. By monitoring saturation levels, the nurse can promptly identify any oxygenation issues and adjust the oxygen delivery if necessary. Encouraging fluid intake, changing oxygen tubing daily, and assisting with frequent position changes are also important aspects of care for a client with pneumonia, but they are not as critical as monitoring oxygen saturation levels in ensuring immediate respiratory support.

4. A healthcare professional is assessing the pain level of a client who has dementia and difficulty communicating. Which pain assessment technique should the healthcare professional use?

• A. Numeric rating scale
• B. Behavioral indicators
• C. Visual analog scale
• D. Faces pain scale

Correct answer: B

Rationale: For clients with dementia who have difficulty communicating, assessing pain using behavioral indicators like increased agitation and restlessness is more effective than relying on self-reported scales such as numeric rating scale, visual analog scale, or faces pain scale. Behavioral indicators provide valuable insights into pain perception in individuals who may have challenges expressing themselves verbally.

5. A charge nurse on a med-surg unit is preparing to delegate tasks to a licensed practical nurse (LPN). What task should the charge nurse delegate to the LPN?

• A. Initiate a care plan.
• B. Perform a complex wound dressing change.
• C. Administer an oral antibiotic to a patient.
• D. Complete an initial assessment.

Correct answer: C

Rationale: The correct task that the charge nurse should delegate to the LPN is to administer an oral antibiotic to a patient. LPNs are trained and permitted to administer medications orally under the supervision of a registered nurse. Initiating a care plan (Choice A) and completing an initial assessment (Choice D) are tasks that typically require higher-level nursing education and critical thinking skills, which are more suitable for registered nurses. Performing a complex wound dressing change (Choice B) involves specialized skills and assessment that are often within the scope of practice of registered nurses or wound care specialists.

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