Nursing Elites

1. A nurse enters a client's room and finds her on the floor. The client's roommate reports that the client was trying to get out of bed and fell over the bedrail onto the floor. Which of the following statements should the nurse document about this incident?

• A. Found on floor
• B. Client slipped while getting out of bed
• C. Patient fell while attempting to get out of bed
• D. Roommate reported fall

Correct answer: A

Rationale: The correct answer is 'A: Found on floor.' This choice provides a clear and objective account of the situation without adding interpretation or assumptions. It is crucial to document only the facts observed directly. Choices B and C introduce speculation by suggesting how the incident happened, which the nurse did not witness. Choice D is not directly related to the nurse’s observation and should not be documented as the primary incident.

2. A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?

• A. Drowsy but responsive when her name is called
• B. SaO2 94%
• C. Respiratory rate 8/min
• D. Pain level of 6 on a scale from 0 to 10

Correct answer: C

Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.

3. A patient is receiving an opioid analgesic for pain management. What is the most important assessment for the nurse to perform?

• A. Monitor the patient's blood pressure.
• B. Assess the patient's respiratory rate.
• C. Monitor the patient's oxygen saturation.
• D. Assess the patient's heart rate.

Correct answer: B

Rationale: The correct answer is to assess the patient's respiratory rate. When a patient is receiving opioids, it is crucial to monitor their respiratory rate as opioids can depress the respiratory system, leading to respiratory depression and potential respiratory failure. Monitoring blood pressure, oxygen saturation, and heart rate are important assessments as well, but the priority lies in assessing respiratory rate due to the risk of respiratory depression associated with opioid use.

4. When providing discharge instructions for a patient with diabetes, what is the most important information to include?

• A. Encourage the patient to maintain a high-carbohydrate diet.
• B. Teach the patient how to monitor their blood sugar levels.
• C. Recommend the patient engage in regular exercise.
• D. Provide the patient with a list of restricted foods.

Correct answer: B

Rationale: The most critical information to include when providing discharge instructions for a patient with diabetes is teaching them how to monitor their blood sugar levels. This empowers the patient to actively manage their condition, make informed decisions about their diet and medication, and prevent complications. Encouraging a high-carbohydrate diet (Choice A) can be detrimental for diabetic patients as it may lead to unstable blood sugar levels. While regular exercise (Choice C) is important in diabetes management, monitoring blood sugar levels takes precedence. Providing a list of restricted foods (Choice D) is relevant but not as crucial as teaching the patient how to monitor their blood sugar levels.

5. A health care provider asks the nurse who is caring for a client with a new colostomy to ask the hospital's stoma nurse to visit the client. What is the nurse's responsibility?

• A. Contact the stoma nurse immediately.
• B. Educate the client on stoma care.
• C. Assess the stoma site for complications.
• D. Arrange for follow-up visits with the stoma nurse.

Correct answer: B

Rationale: The correct answer is B: 'Educate the client on stoma care.' The nurse's primary responsibility in this scenario is to provide education to the client on stoma care. This empowers the client to take care of their colostomy effectively. While it is important to involve the stoma nurse for specialized care, the immediate action required from the nurse is client education. Choice A is incorrect as the immediate action is not to contact the stoma nurse but to educate the client first. Choice C is not the nurse's initial responsibility unless there are obvious complications. Choice D is premature as arranging follow-up visits should come after the client has been educated and initial care has been provided.

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