Nursing Elites

1. A nurse is assessing a client with osteoporosis who is experiencing severe pain. The client's respiratory rate is 14/min. Which of the following medications should the nurse administer first?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: The correct answer is B, Hydromorphone. Hydromorphone is an opioid analgesic commonly used to manage severe pain effectively. In this case, the client's stable respiratory rate of 14/min indicates that it is safe to administer an opioid for pain relief. Promethazine (choice A) is an antiemetic and antihistamine, not the first choice for severe pain management. Ketorolac (choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may not be potent enough for severe pain relief associated with osteoporosis. Amitriptyline (choice D) is a tricyclic antidepressant, not typically used as a first-line medication for severe pain.

2. A nurse is assessing a client who reports chest pain. Which of the following findings should cause the nurse to suspect a myocardial infarction?

• A. Pain improves with rest
• B. Pain radiates to the left arm.
• C. Pain worsens with deep breathing.
• D. Pain is relieved by antacids.

Correct answer: B

Rationale: The correct answer is B. Radiating pain, especially to the left arm, is a classic sign of myocardial infarction. Pain that radiates to the left arm indicates cardiac involvement, making it a significant finding. Choices A, C, and D are incorrect because chest pain that improves with rest, worsens with deep breathing, or is relieved by antacids is less likely to be associated with a myocardial infarction.

3. A nurse receives a report on four clients. Which client should the nurse assess first?

• A. A client scheduled for chemotherapy with a hemoglobin of 9 g/dL
• B. A client 24 hours post-TURP with small blood clots in the catheter
• C. A client receiving a blood transfusion who reports low back pain
• D. A client with a new colostomy and a reddish-pink stoma

Correct answer: C

Rationale: The correct answer is C. Low back pain during a blood transfusion is a classic sign of a transfusion reaction, specifically a transfusion-associated circulatory overload (TACO) or hemolytic reaction, both of which require immediate attention to prevent serious complications. Assessing this client first is crucial to ensure prompt intervention. Choices A, B, and D do not indicate immediate life-threatening complications and can be addressed after the client experiencing low back pain during a blood transfusion is stabilized.

4. A healthcare professional is assessing a client for signs of hypoglycemia. Which of the following findings should the healthcare professional look for?

• A. Increased thirst
• B. Fatigue
• C. Weight gain
• D. Elevated blood pressure

Correct answer: B

Rationale: The correct answer is B: Fatigue. Fatigue, along with symptoms like shakiness and irritability, are common signs of hypoglycemia. Increased thirst (Choice A) is more indicative of hyperglycemia. Weight gain (Choice C) is not typically associated with hypoglycemia. Elevated blood pressure (Choice D) is not a common sign of hypoglycemia.

5. A nurse is providing teaching to a client who has mild persistent asthma and has been prescribed montelukast. Which of the following statements should the nurse include in the teaching?

• A. This medication can be used to help manage asthma symptoms during an acute asthma attack
• B. This medication should be taken before exercise and physical activity
• C. This medication should be taken regularly as prescribed without discontinuing abruptly
• D. This medication helps decrease swelling and mucus production

Correct answer: D

Rationale: Montelukast works as a leukotriene receptor antagonist, reducing inflammation and mucus production, which helps prevent asthma attacks but is not used for acute treatment. It is important for the client to understand that montelukast should be taken regularly to manage asthma symptoms and should not be abruptly discontinued. Taking the medication before exercise is not a typical instruction for montelukast.

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