Nursing Elites

1. While caring for a client receiving morphine, what assessment is the priority for a nurse to conduct?

• A. Blood pressure
• B. Heart rate
• C. Respiratory rate
• D. Temperature

Correct answer: C

Rationale: The correct answer is monitoring the respiratory rate. Morphine can depress respiratory function, leading to respiratory depression or arrest. Therefore, closely monitoring the client's respiratory rate is crucial to detect any signs of respiratory distress. While blood pressure, heart rate, and temperature are important assessments, in this scenario, respiratory rate takes precedence due to the potential respiratory complications associated with morphine administration.

2. A client had a left hip arthroplasty. Which of the following interventions should the nurse use to prevent dislocation?

• A. Maintain foam wedge between legs
• B. Monitor for shortening of the affected leg
• C. Encourage use of elastic stockings
• D. Avoid flexing the hips more than 60 degrees

Correct answer: A

Rationale: The correct answer is to maintain a foam wedge between the legs. This intervention helps prevent hip dislocation by maintaining proper leg alignment after surgery. Monitoring for shortening of the affected leg (choice B) is not directly related to preventing dislocation. Encouraging the use of elastic stockings (choice C) is more related to preventing deep vein thrombosis rather than dislocation. Avoiding flexing the hips more than 60 degrees (choice D) is important post-surgery, but it is not the most direct intervention to prevent dislocation.

3. A healthcare provider writes a medication order that seems excessively high for the patient's condition. What is the nurse's first step?

• A. Administer the medication immediately.
• B. Hold the medication and consult the provider.
• C. Reduce the dose without consulting the provider.
• D. Administer the medication after double-checking with another nurse.

Correct answer: B

Rationale: The correct first step for the nurse when encountering a medication order that appears excessively high for the patient's condition is to hold the medication and consult the provider. Administering the medication immediately (Choice A) without clarification could pose a risk to the patient's safety. Reducing the dose without consulting the provider (Choice C) is not recommended as it may lead to suboptimal treatment. Administering the medication after double-checking with another nurse (Choice D) is not sufficient; consulting the provider directly is crucial to ensure the accuracy and safety of the medication order.

4. A client with a history of falls is being admitted to the unit. What intervention should the nurse implement first?

• A. Increase the client's medication to ensure they don't fall.
• B. Use bed alarms to monitor the client's movements.
• C. Encourage the client to use a walker for mobility.
• D. Assign the client to a nursing assistant for supervision.

Correct answer: B

Rationale: The correct answer is B: 'Use bed alarms to monitor the client's movements.' When a client with a history of falls is admitted, the nurse's initial intervention should focus on fall prevention measures. Using bed alarms to monitor the client's movements can help alert the healthcare team if the client attempts to get out of bed and reduce the risk of falls. Choice A is incorrect because increasing medication should not be the first intervention as it may not address the underlying causes of falls and can have adverse effects. Choice C may be appropriate but is not the priority over implementing safety measures like bed alarms. Choice D is incorrect as assigning the client to a nursing assistant for supervision alone may not be as effective as utilizing bed alarms for continuous monitoring.

5. A healthcare professional is reviewing the notes written by a previous shift. Which documentation reflects proper guidelines?

• A. Incomplete entries are acceptable as long as they are justified
• B. Documentation should include objective observations only
• C. Corrections in documentation should be signed and dated
• D. Entries should be modified by another healthcare professional if necessary

Correct answer: B

Rationale: The correct answer is B. Proper documentation should include objective observations and detailed notes to ensure continuity of care. Choice A is incorrect because incomplete entries can lead to gaps in information and compromise patient care. Choice C is not completely accurate as corrections should be made in a manner that does not obscure the original entry but does not necessarily require a signature. Choice D is incorrect as entries should ideally be corrected by the original author to maintain accountability and accuracy.

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