Nursing Elites

1. A nurse is preparing to administer a high dose of morphine to a patient with terminal cancer. What is the nurse's primary consideration before administration?

• A. Ensure the family is aware of the dosage to be administered.
• B. Monitor the patient for respiratory depression.
• C. Administer the morphine in divided doses.
• D. Delay administration until the next assessment.

Correct answer: B

Rationale: The correct answer is B: Monitor the patient for respiratory depression. When administering a high dose of morphine, the nurse's primary consideration should be to monitor the patient for respiratory depression, as morphine can slow down breathing, especially in higher doses. Option A is incorrect because the primary focus should be on the patient's well-being and safety rather than family awareness at this point. Option C is not the best approach as the immediate concern is monitoring the patient closely for any adverse effects. Option D is not advisable as delaying administration without a valid reason can compromise pain management in a terminal cancer patient.

2. A nurse is assessing a client who is receiving a continuous IV infusion of heparin. Which of the following findings should the nurse report to the provider?

• A. Report any urine output greater than 30 mL/hr.
• B. Bruising on the arms and legs.
• C. Positive Trousseau's sign.
• D. Urine output of 60 mL/hr.

Correct answer: B

Rationale: The correct answer is B. Bruising on the arms and legs is a sign of bleeding, which is a serious complication of heparin therapy and should be reported immediately to the provider. Option A is incorrect as urine output greater than 30 mL/hr is a normal finding. Option C, positive Trousseau's sign, is associated with hypocalcemia, not heparin therapy. Option D, urine output of 60 mL/hr, is within the normal range and does not indicate a complication of heparin therapy.

3. While reviewing a client's chart, a nurse notices a discrepancy in the medication record. What should the nurse do?

• A. Correct the discrepancy and document the correction.
• B. Report the discrepancy to the nurse manager.
• C. Ignore the discrepancy assuming it is a clerical error.
• D. Discuss the discrepancy with the client and adjust the records.

Correct answer: B

Rationale: Reporting medication discrepancies to the nurse manager is crucial to ensure patient safety and proper follow-up. The nurse manager is responsible for addressing medication errors and implementing necessary corrective actions. Choice A is incorrect because simply correcting the discrepancy without reporting it may lead to potential harm to the patient and violates professional standards. Choice C is incorrect as ignoring the discrepancy increases the risk of medication errors going unresolved. Choice D is incorrect because discussing the discrepancy with the client before verifying the accuracy of the record can cause confusion and compromise patient safety.

4. When educating a patient with hypertension about lifestyle changes, what is the most crucial advice to provide?

• A. Advise the patient to reduce salt intake.
• B. Instruct the patient to limit alcohol consumption.
• C. Recommend the patient to exercise for 30 minutes every day.
• D. Instruct the patient to avoid high-cholesterol foods.

Correct answer: A

Rationale: The most critical lifestyle change for a patient with hypertension is to reduce salt intake. Excessive salt consumption can lead to increased blood pressure levels. While limiting alcohol consumption (Choice B) and regular exercise (Choice C) are also beneficial for managing hypertension, reducing salt intake has a more direct impact on blood pressure control. Avoiding high-cholesterol foods (Choice D) is important for heart health but may not have as significant an impact on blood pressure as reducing salt intake.

5. Which of the following is an adverse effect of Lithium Carbonate that requires client education?

• A. Increased risk of infection
• B. Gastrointestinal distress
• C. Increased white blood cell count
• D. Nausea and vomiting

Correct answer: B

Rationale: The correct answer is B: Gastrointestinal distress. When taking Lithium Carbonate, clients may experience gastrointestinal distress as an adverse effect. It is crucial to educate clients about this potential side effect to help them manage it effectively. Choices A, C, and D are incorrect. Increased risk of infection (Choice A) is not a typical adverse effect of Lithium Carbonate. Similarly, increased white blood cell count (Choice C) is not associated with this medication's adverse effects. Nausea and vomiting (Choice D) are general side effects of many medications but are not specifically attributed to Lithium Carbonate.

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