Nursing Elites

1. Before administering the prescribed morphine sulfate to a client post-op following laparotomy who reports pain and dry mouth, what should the nurse do first?

• A. Measure the client's vital signs.
• B. Assess the client's pain level.
• C. Verify the morphine order with another nurse.
• D. Check the client's last dose of morphine.

Correct answer: A

Rationale: Before administering morphine sulfate, it is crucial to measure the client's vital signs to ensure that the client is stable and safe to receive the medication. This step helps identify any contraindications or abnormalities that could affect the administration of morphine. Assessing the client's pain level (choice B) is important, but ensuring the client's physiological stability takes precedence. Verifying the morphine order with another nurse (choice C) and checking the client's last dose of morphine (choice D) are important steps but are not the priority before administering the medication.

2. A nurse is collecting a blood pressure reading from a client who is sitting in a chair. The nurse determines that the client's BP is 158/96 mmHg. Which of the following actions should the nurse take?

• A. Ensure that the width of the BP cuff is appropriate for the client's arm circumference.
• B. Reposition the client supine and recheck their BP.
• C. Recheck the client's BP and measure their other arm for comparison.
• D. Request that another nurse check the client's BP in 30 minutes.

Correct answer: C

Rationale: When a nurse obtains a blood pressure reading that is elevated, the appropriate action is to recheck the client's BP and measure the other arm for comparison. This step helps ensure accuracy by ruling out errors like improper cuff size, positioning, or equipment malfunction. Repositioning the client supine is not necessary unless the client shows signs of distress or symptoms. Ensuring the appropriate cuff width is important for accurate readings but does not address the immediate need to confirm the current BP. Requesting another nurse to check the BP in 30 minutes delays immediate action and does not address the need for verification and comparison of the current reading.

3. While being prepared for transport to the operating room, a client scheduled for hysterectomy informs the nurse that she no longer wants to have surgery. What action should the nurse take?

• A. Notify the provider about the client's decision
• B. Proceed with the transport
• C. Prepare the surgical site
• D. Document the client’s statement

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to notify the provider about the client's decision. By informing the provider, they can discuss the client's change in decision, explore the reasons behind it, and determine the appropriate course of action. Proceeding with the transport (Choice B) without addressing the client's concerns would not respect the client's autonomy and right to make decisions about their own healthcare. Preparing the surgical site (Choice C) would be premature and inappropriate if the client no longer wishes to proceed with the surgery. While documenting the client's statement (Choice D) is important for documentation purposes, the immediate priority is to involve the provider in the decision-making process.

4. The healthcare professional is evaluating the body alignment of a patient in the sitting position. Which observation will indicate a normal finding?

• A. The edge of the seat is making contact with the popliteal space.
• B. Both feet are supported on the floor with ankles flexed.
• C. The body weight is solely on the buttocks.
• D. The arms hang comfortably at the sides.

Correct answer: B

Rationale: In a normal sitting position, both feet should be supported on the floor with the ankles comfortably flexed. This position helps in maintaining stability and proper alignment. Choice A is incorrect because the edge of the seat pressing against the popliteal space may cause discomfort and is not indicative of proper alignment. Choice C is incorrect as the body weight should be evenly distributed for proper alignment and comfort, not solely on the buttocks. Choice D is incorrect as the position of the arms alone does not indicate proper body alignment in the sitting position; proper arm positioning is important for comfort but not a key indicator of body alignment.

5. A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

• A. Monitor the client for pain in the suprapubic region.
• B. Ensure the client is free of metal objects.
• C. Administer 240 mL (8 oz) of oral contrast before the procedure.
• D. Assist the client with a bowel cleansing.

Correct answer: B

Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.

Similar Questions