Nursing Elites

1. A client with vision loss is being cared for by a nurse. Which of the following actions should the nurse take?

• A. Keep objects in the client's room in the same place
• B. Ensure there is high-wattage lighting in the client's room
• C. Approach the client from the side
• D. Touch the client gently to announce presence

Correct answer: A

Rationale: The correct action for the nurse to take is to keep objects in the client's room in the same place. This helps individuals with vision loss navigate their environment more easily by creating a familiar and consistent layout. Choice B, ensuring high-wattage lighting, may not be suitable for all clients with vision loss and can cause discomfort or glare. Approaching the client from the side (Choice C) can startle them and is not recommended. Touching the client (Choice D) without warning may cause anxiety or distress, so it's important to announce presence verbally.

2. A nurse is assessing a client who is receiving enteral feedings through a nasogastric tube. Which of the following findings requires immediate intervention?

• A. Aspirating 100 mL of gastric residual
• B. Gastric pH of 4
• C. Auscultating crackles in the lung bases
• D. Checking residual every 6 hours

Correct answer: C

Rationale: Auscultating crackles in the lung bases indicates fluid in the lungs, which can be a sign of aspiration pneumonia or pulmonary edema and requires immediate intervention to prevent respiratory distress. Aspirating 100 mL of gastric residual is within the acceptable range and does not require immediate intervention. A gastric pH of 4 is normal for gastric contents. Checking residual every 6 hours is a routine nursing intervention and does not indicate an urgent issue like pulmonary complications.

3. A healthcare professional is assessing a client receiving morphine via a patient-controlled analgesia (PCA) pump. Which of the following findings should the healthcare professional identify as an adverse effect of the medication?

• A. Diarrhea.
• B. Urinary retention.
• C. Hypotension.
• D. Bradycardia.

Correct answer: C

Rationale: Hypotension is a common adverse effect of morphine due to its vasodilatory properties. It can lead to a drop in blood pressure, which should be closely monitored during administration. Diarrhea (Choice A) is not a typical adverse effect of morphine. Urinary retention (Choice B) is a side effect of morphine due to its impact on the bladder muscles, but it is not classified as an adverse effect. Bradycardia (Choice D) is not a common adverse effect of morphine; instead, it tends to cause tachycardia.

4. A nurse is assessing a client who is receiving magnesium sulfate for preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Respiratory rate 16/min.
• B. Blood pressure 118/78 mm Hg.
• C. Urinary output of 30 mL/hr.
• D. Absent deep-tendon reflexes.

Correct answer: D

Rationale: The correct answer is D. Absent deep-tendon reflexes indicate magnesium toxicity and should be reported immediately. Magnesium sulfate is used to prevent seizures in clients with preeclampsia, but toxicity can lead to serious complications, including respiratory depression and loss of deep-tendon reflexes. Choices A, B, and C are within normal limits and expected findings in a client receiving magnesium sulfate for preeclampsia, so they do not require immediate reporting.

5. A nurse is teaching a newly licensed nurse about ergonomic principles. Which of the following actions by the newly licensed nurse indicates an understanding of the teaching?

• A. Stands with feet together when lifting a client up in bed.
• B. Raises the client's head of bed before pulling the client up.
• C. Uses a mechanical lift to move a client from bed to chair.
• D. Places a gait belt around the client's upper chest before assisting the client to stand.

Correct answer: C

Rationale: The correct answer is C because using a mechanical lift is an ergonomic practice that ensures safe body mechanics and prevents injuries. Choice A is incorrect as standing with feet together when lifting a client does not promote proper body mechanics. Choice B is incorrect as raising the client's head of bed before pulling the client up is not directly related to ergonomic principles. Choice D is incorrect as placing a gait belt around the client's upper chest is a safety measure for assisting with standing but does not address ergonomic principles.

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