Nursing Elites

1. The nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?

• A. Monitor the client's respiratory status
• B. Teach the client how to use the PCA pump
• C. Evaluate the client's pain level
• D. Assess the client's pain level

Correct answer: A

Rationale: The correct answer is to monitor the client's respiratory status. When administering opioids like morphine sulfate via a PCA pump, it is crucial to closely monitor the client's respiratory status to detect signs of respiratory depression early. This is important for ensuring the client's safety while receiving pain management. Choices B, C, and D are incorrect because while teaching the client to use the PCA pump and assessing or evaluating their pain level are essential aspects of care, monitoring respiratory status takes precedence due to the potential risks associated with opioid use.

2. A client with a C-6 spinal injury changes to a breathing pattern of shallow respirations and dyspnea twelve hours after the causative incident. The nurse should notify the healthcare provider and implement which intervention?

• A. Place the client in reverse Trendelenburg position
• B. Prepare for intubation with an endotracheal tube
• C. Administer a pain medication to the client
• D. Instruct the client on deep breathing exercises

Correct answer: B

Rationale: In a client with a C-6 spinal injury exhibiting shallow respirations and dyspnea, these signs could indicate respiratory compromise and potential respiratory failure. Intubation with an endotracheal tube may be necessary to secure the airway and support adequate oxygenation. Placing the client in reverse Trendelenburg position, administering pain medication, or instructing on deep breathing exercises would not directly address the urgency of the respiratory distress in this situation, making them incorrect choices.

3. A client in the oliguric phase of acute renal failure (ARF) has a 24-hour urine output of 400 ml. How much oral intake should the nurse allow this client to have during the next 24 hours?

• A. Encourage oral fluids as tolerated
• B. Decrease oral intake to 200 ml
• C. Allow the client to have exactly 400 ml oral intake
• D. Limit oral intake to 900 to 1,000 ml

Correct answer: D

Rationale: In the oliguric phase of acute renal failure (ARF), the goal is to prevent fluid overload. Since the client has a low urine output of 400 ml in 24 hours, limiting oral intake to 900 to 1,000 ml is appropriate. Encouraging unrestricted oral fluids (Choice A) can exacerbate fluid overload. Decreasing oral intake to 200 ml (Choice B) would be too restrictive and may lead to dehydration. Allowing the client to have exactly 400 ml oral intake (Choice C) would not account for other sources of fluid intake and output, potentially resulting in fluid imbalance.

4. A female client on the mental health unit tells the nurse that her roommate is sitting on the bathroom floor with superficial cuts on her wrists. The nurse cleans and assesses the client's wrists and asks what happened. She doesn't respond. What should the nurse do next?

• A. Find supplies to put a dressing on the client's wrists
• B. Take the client to a room for supervision by staff
• C. Call the healthcare provider to report the client's behavior
• D. Go find a staff member to stay in the room with the client

Correct answer: B

Rationale: In this situation, the nurse should prioritize the safety of the client. Taking the client to a room for supervision by staff is crucial to ensure immediate safety and further assessment of the client's condition. While cleaning and assessing the client's wrists are important, ensuring ongoing safety and monitoring by staff is the priority. Calling the healthcare provider at this moment may cause delays in providing immediate assistance. Finding supplies to put a dressing on the client's wrists can wait until the client is in a safe environment. Therefore, option B is the best course of action to address the client's safety needs promptly.

5. A client with a history of congestive heart failure (CHF) is admitted with fluid volume overload. Which assessment finding should the nurse report to the healthcare provider?

• A. Weight gain of 2 pounds in 24 hours
• B. Presence of a cough
• C. Edema in the lower extremities
• D. Shortness of breath

Correct answer: D

Rationale: The correct answer is 'D - Shortness of breath.' In a client with congestive heart failure experiencing fluid volume overload, shortness of breath is a critical finding that indicates possible pulmonary congestion and worsening heart failure. This symptom requires immediate attention to prevent further complications. Choices A, B, and C are common findings in clients with CHF but are not as urgent as shortness of breath. Weight gain may indicate fluid retention, cough can be due to pulmonary congestion, and edema in lower extremities is a common manifestation of CHF, but none of these findings are as concerning as shortness of breath in this scenario.

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