Nursing Elites

1. A client is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Respiratory rate of 10/min
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. While a heart rate of 88/min, pain rating of 4, and a temperature of 37.2°C (99°F) are within normal ranges and do not indicate immediate concern related to morphine administration.

2. A nurse is assessing a client who has chronic heart failure. Which of the following findings indicates that the client is experiencing fluid overload?

• A. Increased urine output
• B. Bounding peripheral pulses
• C. Weight loss
• D. Decreased heart rate

Correct answer: B

Rationale: In clients with chronic heart failure, bounding peripheral pulses are a classic sign of fluid overload. This occurs due to increased volume in the arterial system, causing a forceful pulse. Increased urine output (Choice A) is often seen in clients with fluid volume deficit, not overload. Weight loss (Choice C) is also inconsistent with fluid overload as it suggests a fluid deficit. Decreased heart rate (Choice D) is more commonly associated with conditions like bradycardia, hypothyroidism, or the use of certain medications, but not specifically indicative of fluid overload in chronic heart failure.

3. What is the best initial action when a patient presents with confusion?

• A. Administer IV fluids
• B. Perform a neurological assessment
• C. Administer electrolytes
• D. Prepare for a CT scan

Correct answer: B

Rationale: When a patient presents with confusion, the best initial action is to perform a neurological assessment. This assessment helps in identifying potential causes of confusion such as neurological issues, infections, metabolic abnormalities, or medication side effects. Administering IV fluids (Choice A) may be necessary based on assessment findings, but it is not the first step. Administering electrolytes (Choice C) would also depend on the assessment results. Preparing for a CT scan (Choice D) may be indicated later in the diagnostic process but is not the initial action when a patient presents with confusion.

4. Which lab value is critical for patients on warfarin therapy?

• A. Monitor INR
• B. Monitor potassium levels
• C. Monitor sodium levels
• D. Monitor platelet count

Correct answer: A

Rationale: The correct answer is to monitor INR levels for patients on warfarin therapy. INR monitoring is essential because it helps assess the clotting tendency of the blood and ensures that patients are within the therapeutic range to prevent both blood clots and excessive bleeding. Monitoring potassium levels (Choice B), sodium levels (Choice C), or platelet count (Choice D) is not specifically required for patients on warfarin therapy and does not directly impact the effectiveness or safety of the medication.

5. A client scheduled for a thoracentesis requires assistance from a nurse. Which of the following actions should the nurse take?

• A. Assist the client to a prone position.
• B. Assist the client to a sitting position.
• C. Assist the client to a supine position.
• D. Assist the client to a lateral position.

Correct answer: B

Rationale: The correct answer is to assist the client to a sitting position. Placing the client in a sitting position helps facilitate easier access during the thoracentesis procedure by allowing gravity to assist in the removal of pleural fluid. Placing the client in a prone, supine, or lateral position would not provide the optimal positioning needed for a thoracentesis and could make the procedure more challenging or uncomfortable for the client.

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