Nursing Elites

1. A healthcare provider is assessing a client who has received a preoperative dose of morphine. Which of the following findings is the priority to report to the provider?

• A. Client reports nausea.
• B. Urinary output of 20 mL/hr.
• C. Oxygen saturation 90%.
• D. Respiratory rate 14/min.

Correct answer: C

Rationale: An oxygen saturation of 90% is below the expected reference range and could indicate respiratory depression, a serious side effect of morphine. This finding requires immediate attention as it may lead to hypoxia. Nausea (choice A) is a common side effect of morphine but does not pose an immediate threat. A urinary output of 20 mL/hr (choice B) may indicate decreased renal perfusion but is not as critical as respiratory compromise. A respiratory rate of 14/min (choice D) is within the normal range and does not suggest immediate danger.

2. What are the complications of diabetic ketoacidosis?

• A. Electrolyte imbalance and dehydration
• B. Hypoglycemia and increased urination
• C. Kidney failure and respiratory distress
• D. Liver failure and hypertension

Correct answer: A

Rationale: The correct answer is A: Electrolyte imbalance and dehydration. Diabetic ketoacidosis can lead to imbalances in electrolytes such as potassium, sodium, and chloride, as well as dehydration due to excess urination and vomiting. These complications should be managed promptly with appropriate fluids and insulin. Choices B, C, and D are incorrect. Hypoglycemia and increased urination are not typical complications of diabetic ketoacidosis; kidney failure and respiratory distress may occur in severe cases but are not the primary complications. Liver failure and hypertension are not directly associated with diabetic ketoacidosis.

3. A client has developed phlebitis at the IV site. What should the nurse do immediately?

• A. Apply a warm compress over the IV site
• B. Discontinue the IV and notify the provider
• C. Monitor the site for signs of infection
• D. Administer an anti-inflammatory medication

Correct answer: B

Rationale: When a client develops phlebitis at the IV site, the immediate action the nurse should take is to discontinue the IV and notify the provider. Phlebitis is inflammation of the vein, and if left untreated, it can lead to serious complications such as infection, thrombosis, or sepsis. Removing the IV line helps prevent further irritation and infection. Applying a warm compress (Choice A) may provide some relief but does not address the root cause. Monitoring for signs of infection (Choice C) is important but not the immediate action needed to address phlebitis. Administering an anti-inflammatory medication (Choice D) may be prescribed by the provider but is not the first step in managing phlebitis.

4. After sustaining a closed head injury and numerous lacerations and abrasions to the face and neck, a five-year-old child is admitted to the emergency room. The client is unconscious and has minimal response to noxious stimuli. Which of the following assessments, if observed by the nurse three hours after admission, should be reported to the physician?

• A. The client has slight edema of the eyelids
• B. There is clear fluid draining from the client's right ear
• C. There is some bleeding from the child's lacerations
• D. The client withdraws in response to painful stimuli

Correct answer: B

Rationale: Clear fluid draining from the ear can indicate cerebrospinal fluid leakage, which is a serious concern after a head injury. This leakage can signify a skull fracture or damage to the meninges, potentially leading to infection. Therefore, it should be reported immediately for further evaluation and management. Choices A, C, and D are typical findings after head trauma and are not as urgent as the presence of clear fluid draining from the ear.

5. A nurse is reviewing the plan of care for a client who is receiving chemotherapy for cancer. Which of the following interventions should the nurse include to prevent infection?

• A. Encourage the client to eat high-protein foods
• B. Encourage the client to drink 2 liters of fluid daily
• C. Instruct the client to use a soft toothbrush
• D. Instruct the client to use a mouthwash containing alcohol

Correct answer: C

Rationale: The correct answer is to instruct the client to use a soft toothbrush. Using a soft toothbrush helps prevent bleeding in clients receiving chemotherapy, who are at risk for mucositis. Encouraging the client to eat high-protein foods (Choice A) is important for overall health but not directly related to preventing infection. Encouraging the client to drink 2 liters of fluid daily (Choice B) is essential for hydration but does not specifically prevent infection. Instructing the client to use a mouthwash containing alcohol (Choice D) is contraindicated as alcohol-containing mouthwashes can cause irritation and dryness in the oral mucosa, increasing the risk of infection.

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