Nursing Elites

1. A healthcare professional is preparing to administer an IV bolus of morphine to a client. Which of the following actions should the healthcare professional take first?

• A. Check the client's respiratory rate.
• B. Administer naloxone.
• C. Check the client's pain level.
• D. Assess the client's blood pressure.

Correct answer: A

Rationale: Correct Answer: Checking the client's respiratory rate is the priority before administering morphine because morphine can depress respiration. This action helps the healthcare professional assess the client's baseline respiratory status and detect any potential respiratory depression that may be exacerbated by morphine. Choice B, administering naloxone, is incorrect because naloxone is used as an antidote for opioid overdose and not routinely administered before giving morphine. Choice C, checking the client's pain level, is important but not the first action to take before administering morphine. Choice D, assessing the client's blood pressure, is also important but not the initial priority compared to evaluating respiratory status when preparing to administer morphine.

2. A nurse is planning care for a client who has pneumonia. Which of the following interventions should the nurse include to promote airway clearance?

• A. Encourage the client to increase fluid intake.
• B. Suction the client every 2 hours.
• C. Perform chest physiotherapy every 8 hours.
• D. Administer oxygen via nasal cannula.

Correct answer: A

Rationale: Encouraging the client to increase fluid intake is essential to promote airway clearance in pneumonia. Adequate hydration helps to thin respiratory secretions, making them easier to expectorate. Suctioning every 2 hours may be too frequent and can lead to airway trauma and irritation. Chest physiotherapy is not typically indicated for pneumonia unless there are specific complications. Administering oxygen via nasal cannula may be necessary to maintain oxygen saturation but does not directly promote airway clearance.

3. A client is receiving furosemide for heart failure. Which of the following findings should the nurse report to the provider?

• A. Weight loss of 0.5 kg (1.1 lb) in 24 hours.
• B. Heart rate of 68/min.
• C. Potassium level of 3.8 mEq/L.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. A heart rate of 68/min is lower than expected and should be reported as it may indicate digoxin toxicity. Choices A, C, and D are within normal limits for a client receiving furosemide for heart failure and do not require immediate reporting. Weight loss may be expected due to diuretic therapy, a potassium level of 3.8 mEq/L is within the normal range, and a urine output of 60 mL/hr indicates adequate renal perfusion.

4. A healthcare provider is planning to delegate client assignments to the assistive personnel. Which of the following tasks is appropriate for the healthcare provider to delegate?

• A. Adjusting the flow rate of the client's oxygen tank.
• B. Collecting a urine sample.
• C. Measuring the client's pain level.
• D. Transporting a client to x-ray.

Correct answer: D

Rationale: The correct answer is 'D: Transporting a client to x-ray.' This task is appropriate for delegation to assistive personnel as it involves transferring the client safely from one location to another, which does not require the specialized skills of a healthcare provider. Adjusting the flow rate of the client's oxygen tank (Choice A) involves making clinical decisions that should be done by a licensed healthcare provider. Collecting a urine sample (Choice B) and measuring the client's pain level (Choice C) require critical thinking and assessment skills that are typically within the scope of practice of licensed healthcare providers, not assistive personnel.

5. A healthcare provider is assessing a client who has pneumonia. Which of the following findings is the priority for the healthcare provider to report?

• A. Crackles in the lung bases
• B. Blood pressure of 100/64 mm Hg
• C. Respiratory rate of 26/min
• D. Heart rate of 86/min

Correct answer: C

Rationale: A respiratory rate of 26/min is a sign of respiratory distress and should be reported promptly in a client with pneumonia. Rapid breathing can indicate inadequate oxygenation and ventilation, which may lead to respiratory failure. Crackles in the lung bases are common in pneumonia but may not be as urgent as a high respiratory rate. A blood pressure of 100/64 mm Hg is slightly low but may not be immediately life-threatening. A heart rate of 86/min is within the normal range for an adult and is not the most critical finding to report.

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