Nursing Elites

1. A nurse is reviewing the medical record of a client who is receiving morphine for pain management. Which of the following findings should the nurse report to the provider?

• A. Heart rate of 88/min
• B. Pain rating of 4 on a scale of 0 to 10
• C. Respiratory rate of 10/min
• D. Temperature of 37.2°C (99°F)

Correct answer: C

Rationale: The correct answer is C. A respiratory rate of 10/min indicates respiratory depression, a serious adverse effect of morphine that should be reported immediately. Options A, B, and D are within acceptable ranges and not indicative of life-threatening complications when administering morphine.

2. What is the appropriate nursing intervention for a patient experiencing a suspected stroke?

• A. Administer thrombolytics
• B. Perform a neurological assessment
• C. Perform a CT scan
• D. Administer oxygen

Correct answer: B

Rationale: Performing a neurological assessment is the appropriate nursing intervention for a patient experiencing a suspected stroke. This assessment helps determine the severity of the stroke, identify potential deficits, and guide further interventions. Administering thrombolytics (Choice A) should only be done after a CT scan to confirm the type of stroke and rule out hemorrhagic stroke. Performing a CT scan (Choice C) is important but is typically done after stabilizing the patient. Administering oxygen (Choice D) is essential to maintain adequate oxygenation, but performing a neurological assessment takes precedence in the immediate management of a suspected stroke.

3. What is the best way to monitor fluid balance in a patient receiving diuretics?

• A. Monitor daily weight
• B. Monitor intake and output
• C. Monitor blood pressure
• D. Check for edema

Correct answer: A

Rationale: Corrected Rationale: Daily weight monitoring is the most accurate way to assess fluid balance in patients receiving diuretics. Monitoring daily weight allows healthcare providers to track changes in fluid status more precisely. While monitoring intake and output (choice B) is essential, it may not provide a comprehensive picture of overall fluid balance. Monitoring blood pressure (choice C) is important but may not directly reflect fluid balance. Checking for edema (choice D) is useful but may not be as sensitive as daily weight monitoring in assessing fluid balance.

4. A nurse is providing discharge teaching to a client who has a new prescription for clopidogrel. Which of the following instructions should the nurse include?

• A. Avoid eating foods that are high in fat.
• B. Monitor for black, tarry stools while taking this medication.
• C. Avoid taking this medication with grapefruit juice.
• D. Take this medication on an empty stomach.

Correct answer: B

Rationale: The correct instruction for the nurse to include is to advise the client to monitor for black, tarry stools while taking clopidogrel. This is important because it helps detect gastrointestinal bleeding, a potential side effect of the medication. Choice A is incorrect as there is no specific requirement to avoid foods high in fat while taking clopidogrel. Choice C is incorrect as grapefruit juice interaction is not a concern with clopidogrel. Choice D is incorrect as clopidogrel can be taken with or without food.

5. A nurse is assessing a client who has hypothyroidism. Which of the following findings should the nurse expect?

• A. Bradycardia
• B. Weight gain
• C. Hypertension
• D. Decreased deep tendon reflexes

Correct answer: D

Rationale: Corrected Rationale: Decreased deep tendon reflexes are a common finding in clients with hypothyroidism due to slowed metabolic processes. The other choices, such as bradycardia (slow heart rate), weight gain, and hypertension (high blood pressure) are not typically associated with hypothyroidism. Bradycardia can occur due to the decreased metabolic rate, but it is not a consistent finding. Weight gain is common but not universal, and hypertension is more commonly associated with hyperthyroidism.

Similar Questions