Nursing Elites

1. A client who is postoperative following a colon resection reports pain. Which of the following actions should the nurse take?

• A. Assist the client in changing positions in bed
• B. Administer a PRN dose of morphine
• C. Encourage the client to use relaxation techniques
• D. Offer the client a back massage

Correct answer: B

Rationale: Administering a PRN dose of morphine is the most appropriate action to manage postoperative pain in a client following a colon resection. Morphine is a potent analgesic commonly used to relieve moderate to severe pain, especially in postoperative settings. While assisting the client to change positions in bed, encouraging relaxation techniques, and offering a back massage can provide comfort and support, they may not be sufficient in managing the pain following a major surgical procedure like a colon resection. Therefore, the priority intervention for acute postoperative pain control in this scenario is to administer medication like morphine.

2. A nurse is caring for a client who has heart failure and is receiving furosemide. Which of the following findings should the nurse identify as a therapeutic effect of the medication?

• A. Increased shortness of breath.
• B. Weight gain of 2.3 kg (5 lb).
• C. Clear lung sounds.
• D. Bounding pulse.

Correct answer: C

Rationale: The correct answer is C: Clear lung sounds. Clear lung sounds indicate a therapeutic effect of furosemide, as the medication helps reduce fluid overload in heart failure. Choice A, increased shortness of breath, is incorrect as furosemide is used to relieve symptoms like shortness of breath. Choice B, weight gain of 2.3 kg (5 lb), is incorrect as furosemide is a diuretic that helps reduce fluid retention leading to weight loss. Choice D, bounding pulse, is incorrect as furosemide does not directly impact the pulse rate.

3. A healthcare provider is assessing a newborn who has a patent ductus arteriosus. Which of the following findings should the provider expect?

• A. Continuous murmur.
• B. Absent peripheral pulses.
• C. Increased blood pressure.
• D. Bounding pulses.

Correct answer: A

Rationale: A continuous murmur is a classic finding in a newborn with patent ductus arteriosus. This murmur is typically heard between the first and second heart sounds and throughout systole. Absent peripheral pulses (choice B) are not typically associated with patent ductus arteriosus. Increased blood pressure (choice C) and bounding pulses (choice D) are not commonly seen with this condition. Therefore, the correct answer is A.

4. A nurse is caring for a client who has right-sided heart failure. Which of the following findings should the nurse expect?

• A. Peripheral edema.
• B. JVD.
• C. Crackles in the lungs.
• D. Hypotension.

Correct answer: B

Rationale: The correct answer is B: JVD. Jugular venous distention (JVD) is a common finding in right-sided heart failure due to fluid overload. This occurs because the right side of the heart is unable to effectively pump blood, leading to congestion and increased venous pressure, which is manifested as JVD. Choices A, C, and D are incorrect. Peripheral edema (choice A) is more commonly associated with left-sided heart failure. Crackles in the lungs (choice C) are indicative of pulmonary edema, often seen in left-sided heart failure. Hypotension (choice D) is not typically seen in right-sided heart failure, as it is more commonly associated with conditions like shock or severe dehydration.

5. A nurse is assessing a school-age child with a urinary tract infection. What symptom should the nurse expect?

• A. Periorbital edema.
• B. Decreased frequency of urination.
• C. Enuresis.
• D. Diarrhea.

Correct answer: C

Rationale: The correct answer is C: Enuresis. Enuresis, which refers to involuntary urination, is a common symptom of urinary tract infections in children. Periorbital edema (choice A) is more commonly associated with conditions like nephrotic syndrome. Decreased frequency of urination (choice B) is not typically seen in urinary tract infections, as these infections often present with increased frequency. Diarrhea (choice D) is not a typical symptom of a urinary tract infection.

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