Nursing Elites

1. A nurse is caring for a patient with heart failure who has developed pulmonary edema. What is the nurse's priority action?

• A. Administer a diuretic as prescribed.
• B. Place the patient in a high Fowler's position.
• C. Administer oxygen via nasal cannula.
• D. Monitor the patient's lung sounds every 2 hours.

Correct answer: B

Rationale: The correct answer is to place the patient in a high Fowler's position. This position helps improve lung expansion and oxygenation in cases of pulmonary edema by reducing venous return to the heart and enhancing respiratory mechanics. Administering a diuretic (Choice A) can be important but is not the priority over positioning in this situation. Administering oxygen (Choice C) is essential, but the priority action for improving oxygenation is the positioning of the patient. Monitoring lung sounds (Choice D) is crucial for ongoing assessment but is not the priority action when the patient is in distress with pulmonary edema.

2. A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?

• A. Drowsy but responsive when her name is called
• B. SaO2 94%
• C. Respiratory rate 8/min
• D. Pain level of 6 on a scale from 0 to 10

Correct answer: C

Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.

3. Which of the following is a recommended approach for handling aggressive behavior in a mental health setting?

• A. Encourage the client to express their feelings through physical activity
• B. Avoid making eye contact to prevent escalation
• C. Use pharmacological interventions immediately
• D. Maintain eye contact, offer clear choices, and set boundaries

Correct answer: D

Rationale: The recommended approach for handling aggressive behavior in a mental health setting is to maintain eye contact, offer clear choices, and set boundaries. This approach can help de-escalate the situation by establishing communication and structure. Choice A is incorrect as encouraging physical activity may not be suitable during an aggressive episode. Choice B is incorrect because avoiding eye contact can hinder communication and resolution. Choice C is also incorrect as pharmacological interventions should not be the immediate go-to method for managing aggression unless absolutely necessary.

4. A client has a new prescription for lisinopril. Which of the following statements indicates an understanding of the teaching?

• A. I should take this medication with food
• B. I should report a cough to my provider
• C. I should expect to have facial swelling when taking this medication
• D. I should increase my intake of potassium-rich foods

Correct answer: B

Rationale: The correct answer is B. Reporting a cough is crucial when taking lisinopril as it can be a sign of a serious side effect, such as angioedema or cough associated with ACE inhibitors. Option A is incorrect because lisinopril can be taken with or without food. Option C is incorrect as facial swelling is not an expected side effect of lisinopril. Option D is incorrect because lisinopril can cause hyperkalemia, so increasing potassium-rich foods without healthcare provider guidance can be dangerous.

5. A patient with a left arm fracture reports severe pain unrelieved by medication. What should the nurse assess for?

• A. Check for compartment syndrome
• B. Increase the pain medication
• C. Prepare the patient for surgery immediately
• D. Administer a sedative to calm the patient

Correct answer: A

Rationale: Correct answer: When a patient with a left arm fracture reports severe pain unrelieved by medication, the nurse should assess for compartment syndrome. Compartment syndrome is a condition where increased pressure within a muscle compartment compromises circulation and can lead to tissue damage. It is a surgical emergency that requires immediate intervention. Choice B is incorrect because simply increasing pain medication without identifying the cause of the unrelieved pain may mask symptoms of a serious issue like compartment syndrome. Choice C is incorrect as surgery would only be necessary if compartment syndrome is confirmed. Choice D is incorrect as administering a sedative does not address the underlying issue of unrelieved pain and may delay appropriate treatment.

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