Nursing Elites

1. A nurse is caring for a client who is receiving morphine sulfate via a patient-controlled analgesia (PCA) pump. Which action is most important for the nurse to implement?

• A. Monitor the client's respiratory status
• B. Teach the client how to use the PCA pump
• C. Evaluate the client's pain level
• D. Assess the client's pain level

Correct answer: A

Rationale: When a client is receiving opioids like morphine sulfate via a PCA pump, the most critical action for the nurse to implement is to monitor the client's respiratory status. Opioids can cause respiratory depression, which can be life-threatening. Monitoring respiratory status allows for early detection of any signs of respiratory compromise. Teaching the client how to use the PCA pump, evaluating pain level, and assessing pain level are important aspects of care but ensuring the client's safety by monitoring respiratory status takes precedence due to the potential risks associated with opioid administration.

2. The nurse is assessing a client who is 2 days post-op following abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?

• A. Apply a sterile saline dressing to the wound
• B. Notify the healthcare provider
• C. Administer pain medication
• D. Cover the wound with an abdominal binder

Correct answer: A

Rationale: In this scenario, the nurse should first apply a sterile saline dressing to the wound. This action helps prevent infection and keeps the wound moist, which is crucial in promoting healing. Option B, notifying the healthcare provider, is important but should come after providing immediate wound care. Option C, administering pain medication, is not the priority when there is a small amount of bowel protruding from the wound. Option D, covering the wound with an abdominal binder, is not appropriate for this situation as it does not address the protruding bowel and potential risk for infection.

3. In the newborn nursery, the nurse admits a baby from labor and delivery who is suspected of having a congenital heart disease. Which finding helps to confirm this diagnosis?

• A. Pink lips and tongue with cyanotic hands and feet
• B. Respiration rate of 40 and heart rate of 144
• C. Centralized cyanosis and tachycardia when crying
• D. Desquamation from areas of cracked, parchment-like skin

Correct answer: C

Rationale: Centralized cyanosis and tachycardia are classic signs of congenital heart disease. Choice A is incorrect because cyanosis in the hands and feet is not specific to congenital heart disease. Choice B is incorrect as the vital signs provided are not specific indicators of congenital heart disease. Choice D is unrelated to the typical signs of congenital heart disease.

4. When obtaining a urine specimen from a female infant, which intervention should the nurse implement?

• A. Place the wet diaper in a biohazard specimen bag
• B. Obtain the urine sample using a straight size 4 French catheter
• C. Collect the urinary stream in mid-air when the infant cries
• D. Secure the pediatric urine collector bag to the perineum

Correct answer: D

Rationale: When obtaining a urine specimen from a female infant, securing the pediatric urine collector bag to the perineum is the most appropriate intervention. This method allows for non-invasive collection of urine without causing discomfort or distress to the infant. Placing the wet diaper in a biohazard specimen bag (Choice A) is incorrect as it does not involve collecting a fresh urine sample. Using a catheter (Choice B) is invasive and not typically necessary for routine urine specimen collection from infants. Collecting the urinary stream in mid-air when the infant cries (Choice C) is not a reliable or hygienic method of obtaining a urine specimen.

5. The healthcare provider prescribes a diet high in vitamin C for a client with a leg wound. Which food should the nurse encourage the client to eat?

• A. Bananas and pineapple
• B. Cottage cheese and crackers
• C. Peanut butter and jelly
• D. Tomato and lettuce salad

Correct answer: D

Rationale: Tomatoes and lettuce are high in vitamin C, making them suitable choices for a diet prescribed for wound healing. Bananas and pineapple (Choice A) are not particularly high in vitamin C compared to tomatoes and lettuce. Cottage cheese and crackers (Choice B) as well as peanut butter and jelly (Choice C) do not provide significant amounts of vitamin C, which is essential for wound healing.

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