Nursing Elites

1. A nurse is caring for a client with a new prescription for lisinopril. Which of the following should the nurse monitor?

• A. Blood pressure
• B. Liver function
• C. Serum potassium levels
• D. Heart rate

Correct answer: A

Rationale: Corrected Rationale: Lisinopril is an ACE inhibitor commonly used to lower blood pressure. Monitoring blood pressure is crucial when initiating this medication to assess its effectiveness and potential side effects related to blood pressure regulation. Liver function monitoring is not typically required with lisinopril. While lisinopril can affect potassium levels, it is not the primary parameter to monitor when starting this medication. Heart rate monitoring is not a routine requirement when initiating lisinopril therapy.

2. The nurse instructs the patient about incentive spirometry as part of preoperative teaching. Which phase of the nursing process does this illustrate?

• A. Assessment
• B. Planning
• C. Implementation
• D. Evaluation

Correct answer: C

Rationale: Instructing a patient about incentive spirometry falls under the implementation phase of the nursing process. During this phase, nursing interventions are put into action. Assessment (choice A) involves collecting data about the patient's condition, planning (choice B) involves setting goals and creating a care plan, and evaluation (choice D) involves assessing the outcomes of nursing interventions. Therefore, the correct answer is C, as it reflects the active teaching and intervention part of the process.

3. A nurse is reviewing psychosocial stages of development for a school-age child. What would be an expected behavioral finding for this child?

• A. Personalize values and beliefs and base reasoning on ethical fairness principles.
• B. Develop a sense of personal identity that is influenced by family expectations.
• C. Develop a sense of industry through advances in learning.
• D. Take on new experiences and when unable to accomplish tasks, may feel guilty.

Correct answer: C

Rationale: The correct answer is C. School-age children (6-12 years) are in Erikson's stage of industry vs. inferiority. During this stage, they strive to develop a sense of industry through learning and socialization. They seek to excel in various areas, such as schoolwork or activities, and look for approval from peers and adults. Choices A, B, and D are incorrect because personalizing values and beliefs, developing personal identity influenced by family expectations, and feeling guilty for inability to accomplish tasks are not typical behavioral findings for a school-age child in the context of psychosocial development.

4. A nurse is planning to administer an injection of morphine to a client. Which of the following actions should the nurse take to ensure client safety?

• A. Instruct the client to take a deep breath during administration.
• B. Administer the medication over 30 seconds.
• C. Verify the client’s pain level.
• D. Have naloxone available in case of respiratory depression.

Correct answer: D

Rationale: The correct answer is to have naloxone available in case of respiratory depression. Morphine is an opioid that can lead to respiratory depression, especially in higher doses. Naloxone is the antidote for opioid overdose and should be readily accessible when administering morphine to reverse respiratory depression if it occurs. Instructing the client to take a deep breath during administration (choice A) is not directly related to ensuring safety in this scenario. Administering the medication over 30 seconds (choice B) may help with the comfort of the client but does not address the potential risk of respiratory depression. Verifying the client's pain level (choice C) is important but not the primary action to ensure safety when administering morphine.

5. A nurse is caring for a client in preterm labor who is receiving magnesium sulfate by continuous IV infusion. Which of the following client findings indicates medication toxicity?

• A. Blood glucose of 150 mg/dL
• B. Urine output of 20 mL per hour
• C. Systolic blood pressure of 140 mm Hg
• D. BUN 20 mg/dL

Correct answer: B

Rationale: A urine output of 20 mL per hour is low and indicates renal insufficiency, a sign of magnesium sulfate toxicity. The medication is excreted by the kidneys, so toxicity can occur if renal function declines. Blood glucose of 150 mg/dL is within normal range and not indicative of magnesium sulfate toxicity. A systolic blood pressure of 140 mm Hg is elevated but not specifically related to magnesium sulfate toxicity. A BUN level of 20 mg/dL is also within normal limits and not a sign of medication toxicity.

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