Nursing Elites

1. A client is receiving morphine for pain. Which of the following assessments is the priority?

• A. Urine output
• B. Pupil reaction
• C. Respiratory rate
• D. Bowel sounds

Correct answer: C

Rationale: The correct answer is C: Respiratory rate. Monitoring the respiratory rate is the priority assessment for a client receiving morphine due to the risk of respiratory depression. Morphine is a potent opioid that can cause respiratory depression, which is a serious adverse effect that can be life-threatening. Assessing the client's respiratory rate is crucial to detect any signs of respiratory depression early and intervene promptly. Assessing urine output is important but not as critical as monitoring for respiratory depression with morphine. Pupil reaction and bowel sounds are also important assessments but do not take precedence over monitoring the respiratory rate when a client is on morphine.

2. A client with chronic heart failure is being discharged with a prescription for digoxin (Lanoxin). Which instruction should the nurse reinforce?

• A. Take the medication at the same time each day.
• B. Avoid foods high in potassium.
• C. Skip a dose if you feel well.
• D. Take the medication on an empty stomach.

Correct answer: A

Rationale: Taking digoxin at the same time each day is essential to maintain a consistent blood level of the medication. This consistency helps optimize the therapeutic effects of digoxin in managing chronic heart failure. Deviating from the scheduled time could lead to fluctuations in drug levels, affecting its effectiveness and potentially causing harm. Choices B, C, and D are incorrect because avoiding potassium-rich foods, skipping doses when feeling well, and taking the medication on an empty stomach are not relevant or appropriate instructions for a client prescribed digoxin.

3. The LPN/LVN is assisting in caring for a client in the telemetry unit who is receiving an intravenous infusion of 1000 mL of 5% dextrose with 40 mEq of potassium chloride. Which occurrence observed on the cardiac monitor indicates the presence of hyperkalemia?

• A. Tall, peaked T waves
• B. ST segment depressions
• C. Shortened P-R intervals
• D. Shortening of the QRS complex

Correct answer: A

Rationale: In hyperkalemia, tall, peaked T waves are a distinct ECG finding. These T waves can be seen as a result of increased serum potassium levels, affecting the repolarization phase of the cardiac action potential. It is crucial for healthcare providers to recognize this ECG change promptly as hyperkalemia can lead to serious cardiac arrhythmias and complications. ST segment depressions, shortened P-R intervals, and shortening of the QRS complex are not typically associated with hyperkalemia. ST segment depressions are more indicative of myocardial ischemia or infarction. Shortened P-R intervals may be seen in conditions like Wolff-Parkinson-White syndrome. Shortening of the QRS complex is associated with conditions affecting the conduction system of the heart, such as bundle branch blocks.

4. A nurse is assessing a client who has a new prescription for albuterol. Which of the following findings should the nurse report to the provider?

• A. Dry mouth
• B. Tachycardia
• C. Weight gain
• D. Drowsiness

Correct answer: B

Rationale: The correct answer is B: Tachycardia. Albuterol is a bronchodilator medication commonly used to treat respiratory conditions such as asthma. Tachycardia, an increased heart rate, can be a potential side effect of albuterol, indicating excessive stimulation of the beta receptors. This side effect should be reported to the healthcare provider promptly to assess the need for further intervention or adjustment of the treatment plan. Choices A, C, and D are incorrect because dry mouth, weight gain, and drowsiness are not typically associated with albuterol use and are less likely to require immediate reporting compared to tachycardia.

5. A client with a history of angina pectoris reports chest pain after climbing stairs. What should be the nurse's first action?

• A. Administer oxygen.
• B. Administer nitroglycerin.
• C. Sit the client down and rest.
• D. Check the client's blood pressure.

Correct answer: C

Rationale: The correct action for a client experiencing anginal pain, like chest pain after climbing stairs, is to sit the client down and have them rest. Resting reduces myocardial oxygen demand, which can help relieve anginal pain. Administering oxygen or nitroglycerin may be appropriate interventions after the client has been seated and rested. Checking the client's blood pressure is important but not the immediate priority when a client is experiencing anginal pain. Therefore, the first action should be to sit the client down and allow them to rest.

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