Nursing Elites

1. A male client with heart failure becomes short of breath, anxious, and has pink frothy sputum. What is the first action the nurse should take?

• A. Consult the charge nurse about administering morphine.
• B. Administer the morphine sulfate as prescribed.
• C. Withhold the morphine until the dyspnea resolves.
• D. Review the need for the morphine prescription with the provider.

Correct answer: B

Rationale: The correct answer is B: Administer the morphine sulfate as prescribed. In this situation, the client is experiencing symptoms of acute pulmonary edema, a complication of heart failure. Morphine is indicated as it helps reduce anxiety and respiratory distress by decreasing preload and afterload. It dilates blood vessels, reducing the workload of the heart and improving oxygenation. The priority is to administer the morphine promptly to alleviate the client's distress and improve oxygenation. Consulting the charge nurse (A) or reviewing the need for the morphine prescription with the provider (D) would cause a delay in providing essential treatment. Withholding the morphine (C) would not be appropriate as it is indicated for this condition.

2. A client with a history of alcohol abuse presents with confusion and unsteady gait. The nurse suspects Wernicke's encephalopathy. Which treatment should the nurse anticipate?

• A. Thiamine supplementation
• B. Folic acid replacement
• C. Intravenous glucose
• D. Magnesium sulfate administration

Correct answer: A

Rationale: Wernicke's encephalopathy is a neurological condition commonly caused by a deficiency in thiamine, often seen in clients with chronic alcohol abuse. Thiamine supplementation is the primary treatment to prevent further neurological damage. Folic acid replacement (choice B) is not the correct treatment for Wernicke's encephalopathy. Intravenous glucose (choice C) may be necessary in some cases of Wernicke's encephalopathy, but thiamine supplementation takes precedence. Magnesium sulfate administration (choice D) is not indicated as the primary treatment for Wernicke's encephalopathy.

3. A client asks the nurse to call the police and states: 'I need to report that I am being abused by a nurse.' The nurse should first

• A. Focus on reality orientation to place and person
• B. Assist with the report of the client's complaint to the police
• C. Obtain more details of the client's claim of abuse
• D. Document the statement in the client's chart with a report to the manager

Correct answer: C

Rationale: The correct initial action for the nurse is to obtain more details about the client's claim of abuse. This will help the nurse better understand the situation before proceeding with any further actions. Option A is incorrect as reality orientation is not the priority in this situation. Option B is premature as more details are needed first. Option D is not the immediate step as gathering information should come before documentation and reporting.

4. The nurse instructs a client to use an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?

• A. Instruct the client to inhale more deeply
• B. Remind the client to cough after using the spirometer
• C. Praise the client for correct usage
• D. Suggest increasing the frequency of spirometer use

Correct answer: B

Rationale: The correct action for the nurse to take in response to the return demonstration of using an incentive spirometer is to remind the client to cough after using the device. Coughing helps clear secretions from the lungs and promotes lung expansion. Instructing the client to inhale more deeply (Choice A) is not necessary as the primary focus after using the spirometer is to clear secretions. Praising the client for correct usage (Choice C) is positive but does not address the essential step of coughing. Suggesting increasing the frequency of spirometer use (Choice D) is not the immediate action needed after the demonstration.

5. A client with congestive heart failure is prescribed digoxin. What symptom indicates digoxin toxicity?

• A. Monitor for muscle weakness and fatigue.
• B. Monitor for increased appetite and weight gain.
• C. Monitor for nausea and vomiting.
• D. Monitor for blurred vision or seeing yellow halos around objects.

Correct answer: D

Rationale: Corrected Rationale: Blurred vision or seeing yellow halos around objects are signs of digoxin toxicity, which can be life-threatening. These symptoms indicate an overdose of digoxin, requiring immediate medical attention. Muscle weakness and fatigue (Choice A) are not typically associated with digoxin toxicity. Increased appetite and weight gain (Choice B) are not indicative of digoxin toxicity either. Nausea and vomiting (Choice C) are common side effects of digoxin but are not specific signs of toxicity. Therefore, the correct answer is to monitor for blurred vision or seeing yellow halos around objects.

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