Nursing Elites

1. A nurse is assessing a client who is receiving morphine via a patient-controlled analgesia (PCA) pump. The nurse should identify that which of the following findings is a manifestation of opioid toxicity?

• A. Bradypnea.
• B. Tachycardia.
• C. Hypertension.
• D. Diaphoresis.

Correct answer: A

Rationale: Corrected Rationale: Bradypnea, or slow breathing, is a common sign of opioid toxicity. When a client is experiencing opioid toxicity, the respiratory system is usually the most affected, leading to a decrease in the respiratory rate (bradypnea). Tachycardia (increased heart rate), hypertension (high blood pressure), and diaphoresis (excessive sweating) are not typical manifestations of opioid toxicity. Therefore, the correct answer is bradypnea.

2. A nurse is assessing a client who has increased intracranial pressure (ICP). Which of the following findings should the nurse expect?

• A. Bradycardia.
• B. Increased level of consciousness.
• C. Tachycardia.
• D. Hyperactive bowel sounds.

Correct answer: C

Rationale: The correct answer is C: Tachycardia. In a client with increased intracranial pressure (ICP), tachycardia is a common finding. This is due to the body's compensatory mechanisms in response to the increased pressure. Bradycardia (choice A) is not typically associated with increased ICP and may indicate a different issue. Increased level of consciousness (choice B) is unlikely with increased ICP, as it often leads to altered mental status. Hyperactive bowel sounds (choice D) are not directly related to increased ICP and are more indicative of gastrointestinal issues.

3. A client with heart failure has a new prescription for furosemide. Which of the following instructions should the nurse include?

• A. You should weigh yourself once a week while taking this medication.
• B. You should eat foods rich in potassium while taking this medication.
• C. You should take this medication at bedtime.
• D. You should take this medication with food to avoid stomach upset.

Correct answer: B

Rationale: The correct answer is B. Clients taking furosemide, a potassium-wasting diuretic, should increase their intake of potassium-rich foods to prevent hypokalemia. Option A is incorrect because weight monitoring is crucial for furosemide due to fluid loss. Option C is incorrect as furosemide is usually taken in the morning to prevent nighttime diuresis. Option D is incorrect because furosemide is best taken on an empty stomach for better absorption.

4. How should fluid balance be assessed in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Check for edema
• D. Monitor blood pressure

Correct answer: A

Rationale: Corrected Rationale: Monitoring daily weight is the most accurate method to assess fluid balance in patients receiving diuretics. Changes in weight reflect changes in fluid balance, making it a sensitive indicator. Monitoring intake and output (choice B) is important but may not provide a complete picture of overall fluid balance. Checking for edema (choice C) is a late sign of fluid imbalance and may not be sensitive enough to detect subtle changes. Monitoring blood pressure (choice D) is relevant but may not directly reflect fluid balance as it can be influenced by various other factors.

5. A client prescribed clozapine is receiving discharge teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. “I should report a sore throat to my provider.”
• B. “I should avoid drinking grapefruit juice while taking this medication.”
• C. “I should take this medication with food.”
• D. “I should avoid taking this medication with food.”

Correct answer: A

Rationale: The correct answer is A. Clozapine can cause agranulocytosis, a serious condition that decreases the number of white blood cells. Reporting a sore throat is crucial as it could be a sign of infection. Choice B is incorrect because there is no specific interaction between clozapine and grapefruit juice. Choice C is incorrect because clozapine is usually taken without regard to meals. Choice D is incorrect as clozapine is generally taken without food to enhance absorption.

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