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. The nurse offers diet teaching to a female college student who was diagnosed with iron-deficiency anemia following her voluntary adoption of a lacto-vegetarian diet. What nutrients should the nurse suggest this client eat to best meet her nutritional needs while allowing her to adhere to a lacto-vegetarian diet?

• A. Drink whole milk instead of skim milk to enhance the body's production of amino acids
• B. Take vitamin K 10mg PO daily to enhance production of red blood cells
• C. Increase amounts of dark yellow vegetables such as carrots to fortify iron stores
• D. Combine several legumes and grains such as beans and rice to form complete proteins

Correct answer: D

Rationale: Combining legumes and grains ensures the client receives all essential amino acids to form complete proteins, which is crucial in a vegetarian diet. Options A, B, and C are incorrect. Option A is not necessary as there are plant-based sources of essential amino acids in a lacto-vegetarian diet. Option B suggests vitamin K, which is not directly related to enhancing red blood cell production. Option C mentions increasing dark yellow vegetables, which are sources of non-heme iron, but combining legumes and grains is more effective in addressing the protein needs of a lacto-vegetarian.

3. A male client is admitted to the mental health unit because he experiences panic attacks when driving on the freeway. To attempt to desensitize this fear, what action should the nurse encourage the client to implement?

• A. Watch training videos of people driving in various environments
• B. Begin visualizing himself driving each route to the freeway
• C. Take antianxiety medication two hours before driving on freeways
• D. Get in the car with a support person and drive on a freeway during rush hour

Correct answer: B

Rationale: Visualization techniques, such as visualizing himself driving each route to the freeway, are commonly used in desensitization therapy to help clients gradually overcome their fears. Watching videos of others driving or taking medication do not actively involve the client in facing their fear, which is essential in desensitization therapy. Getting in the car with a support person during rush hour may exacerbate the client's anxiety rather than help in desensitization.

4. The nurse is caring for a 10-year-old diagnosed with acute glomerulonephritis. Which outcome is the priority for this child?

• A. Activity tolerance as evidenced by appropriate age-level activities being performed
• B. Absence of skin breakdown as evidenced by intact skin and absence of redness
• C. Maintaining adequate nutritional status as evidenced by stable weight without gain or loss
• D. Maintaining fluid balance as evidenced by a urine output of 1 to 2 ml/kg/hr

Correct answer: D

Rationale: In acute glomerulonephritis, maintaining fluid balance is the priority to prevent complications like fluid overload or dehydration. Monitoring urine output within the range of 1 to 2 ml/kg/hr is crucial in assessing renal function. While activity tolerance, skin integrity, and nutritional status are important aspects of care, fluid balance takes precedence due to its direct impact on the renal condition and overall health outcome for the child.

5. A client with type 2 diabetes mellitus is admitted for antibiotic treatment of a leg ulcer. Which signs and symptoms, indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS), should the nurse report to the healthcare provider? (Select one that doesn't apply.)

• A. Increased heart rate
• B. Visual disturbances
• C. Presence of uremic frost
• D. Decreased mentation

Correct answer: C

Rationale: The correct answer is C, 'Presence of uremic frost.' Increased heart rate, visual disturbances, and decreased mentation are all signs and symptoms indicative of hyperosmolar hyperglycemic nonketotic syndrome (HHNS). Uremic frost, however, is not associated with HHNS but is a clinical finding seen in severe cases of chronic kidney disease. Therefore, the nurse should report the presence of uremic frost to the healthcare provider as a separate concern from HHNS.

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