Nursing Elites

1. A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Respiratory rate of 10/min
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.

2. A nurse is providing discharge teaching to a client who has a new prescription for enoxaparin. Which of the following instructions should the nurse include?

• A. Avoid eating spinach while taking this medication.
• B. Massage the injection site after administration.
• C. Administer the injection into the deltoid muscle.
• D. Inject the medication into the abdomen.

Correct answer: D

Rationale: The correct answer is to inject the medication into the abdomen. Enoxaparin should be administered subcutaneously into the abdomen for optimal absorption. Choice A is incorrect as there is no specific interaction between enoxaparin and spinach. Choice B is incorrect as massaging the injection site after administration is not recommended and can increase bruising. Choice C is incorrect as enoxaparin injections should not be administered into the deltoid muscle.

3. A client has a new prescription for furosemide. Which of the following instructions should the nurse include during discharge teaching?

• A. Avoid prolonged exposure to sunlight.
• B. Take this medication with a meal.
• C. Increase your intake of potassium-rich foods.
• D. Limit your fluid intake to 1 liter per day.

Correct answer: C

Rationale: The correct instruction for a client taking furosemide is to increase their intake of potassium-rich foods. Furosemide is a loop diuretic that can lead to potassium loss, so increasing potassium-rich foods helps prevent hypokalemia. Choice A, avoiding prolonged exposure to sunlight, is not directly related to furosemide use. Choice B, taking the medication with a meal, is not a specific requirement for furosemide administration. Choice D, limiting fluid intake to 1 liter per day, is not the correct advice as furosemide is a diuretic that often requires increased fluid intake to prevent dehydration.

4. A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

• A. Monitor the client's IV site for thrombophlebitis
• B. Administer flumazenil to the client
• C. Evaluate the client for further suicidal behavior
• D. Initiate seizure precautions for the client

Correct answer: B

Rationale: In cases of benzodiazepine overdose, such as diazepam ingestion, flumazenil is the antidote. Therefore, the priority action for the nurse is to administer flumazenil to the client. Monitoring the IV site for thrombophlebitis (Choice A) is important but not the immediate priority. Evaluating the client for further suicidal behavior (Choice C) is important but not the next immediate action. Initiating seizure precautions (Choice D) is not the priority as the client's airway has already been secured.

5. A nurse is caring for a client following the application of a cast. Which of the following actions should the nurse take first?

• A. Place an ice pack over the cast
• B. Palpate the pulse distal to the cast
• C. Teach the client to keep the cast clean and dry
• D. Position the casted extremity on a pillow

Correct answer: B

Rationale: Palpating the pulse distal to the cast is the priority as it assesses for circulation. Ensuring adequate blood flow is essential to prevent complications such as compartment syndrome. Placing an ice pack over the cast could cause constriction of blood vessels, further compromising circulation. Teaching the client about cast care and positioning the casted extremity on a pillow are important but do not take precedence over assessing circulation.

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