Nursing Elites

1. A healthcare professional is caring for a client who has a prescription for morphine 5mg IM but accidentally administers the entire 10mg from the single-dose vial. Which of the following actions should the healthcare professional take first?

• A. Complete an incident report
• B. Measure the client’s respiratory rate
• C. Report the incident to the pharmacy
• D. Notify the client's provider

Correct answer: B

Rationale: Assessing the client's respiratory rate is the priority in this situation as overdosing on morphine can lead to respiratory depression, making it crucial to monitor the client's breathing. Completing an incident report (choice A) is important but should not be the first action. Reporting the incident to the pharmacy (choice C) and notifying the client's provider (choice D) are necessary steps but assessing the client's respiratory status takes precedence to ensure immediate safety and intervention.

2. A client is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client?

• A. The client reports severe pain
• B. The client asks for a demonstration
• C. The client inquires about potential complications
• D. The client agrees to the procedure

Correct answer: A

Rationale: The correct answer is A because severe pain can hinder the client's ability to participate effectively in learning. Pain can be distracting and may prevent the client from focusing on acquiring new information or skills. Choice B is incorrect because asking for a demonstration shows an interest in learning and readiness to understand the exercises. Choice C is incorrect as inquiring about potential complications indicates the client's engagement in understanding the procedure and its outcomes, demonstrating readiness to learn. Choice D is incorrect as agreeing to the procedure does not necessarily reflect a lack of readiness to learn. The client may still be open to receiving information about postoperative care, indicating a level of readiness to learn despite agreeing to the surgery.

3. During an integumentary assessment for a group of clients, a healthcare professional notes various skin findings. Which of the following findings should the professional recognize as requiring immediate intervention?

• A. Pallor
• B. Cyanosis
• C. Jaundice
• D. Erythema

Correct answer: B

Rationale: Cyanosis, a bluish discoloration of the skin, indicates inadequate oxygenation and requires immediate intervention. It suggests a severe lack of oxygen in the blood, which can be life-threatening. Pallor and jaundice are concerning findings but may not indicate an immediate life-threatening situation. Pallor can be a sign of anemia or low blood pressure, while jaundice may indicate liver dysfunction. Erythema, which is redness of the skin, is typically not an emergency and can be caused by various factors such as inflammation or increased blood flow to the area.

4. A client who had a stroke requires assistance with morning ADLs. Which of the following interprofessional team members should the nurse consult?

• A. Registered dietitian.
• B. Occupational therapist.
• C. Speech-language pathologist.
• D. Physical therapist.

Correct answer: B

Rationale: The correct answer is B, Occupational therapist. An occupational therapist specializes in assisting clients with daily living activities, making them crucial for a stroke patient requiring help with morning activities of daily living (ADLs). While a registered dietitian (A) may provide nutritional guidance, a speech-language pathologist (C) focuses on communication and swallowing disorders, and a physical therapist (D) primarily deals with mobility and physical rehabilitation. However, none of these professionals directly address the specific needs related to ADLs following a stroke as effectively as an occupational therapist.

5. During passive range of motion (ROM) and splinting, the absence of which finding will indicate goal achievement for these interventions?

• A. Atelectasis
• B. Renal calculi
• C. Pressure ulcers
• D. Joint contractures

Correct answer: D

Rationale: The correct answer is D: Joint contractures. When a healthcare provider performs passive ROM and splinting on a patient, the goal is to prevent joint contractures. Joint contractures result from immobility and can lead to permanent stiffness and decreased range of motion. Atelectasis (choice A) is a condition where there is a complete or partial collapse of the lung, commonly due to immobility, but not directly related to passive ROM or splinting. Renal calculi (choice B) are kidney stones and are not typically associated with ROM exercises. Pressure ulcers (choice C) result from prolonged pressure on the skin and are prevented by repositioning the patient, not specifically addressed by ROM and splinting exercises.

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