Nursing Elites

1. A patient with severe pain is prescribed morphine sulfate. What is the most important side effect for the nurse to monitor?

• A. Diarrhea
• B. Hypertension
• C. Respiratory depression
• D. Increased urine output

Correct answer: C

Rationale: When a patient is prescribed morphine sulfate, the most critical side effect for the nurse to monitor is respiratory depression. Morphine can suppress the respiratory drive, leading to inadequate ventilation and potentially life-threatening consequences. Monitoring the patient's respiratory status closely is essential to promptly identify and manage any signs of respiratory depression.

2. The client has acute pancreatitis. Which nursing intervention is the highest priority?

• A. Administer pain medication as prescribed.
• B. Monitor the client's serum amylase and lipase levels.
• C. Encourage oral intake of clear liquids.
• D. Assess the client's bowel sounds every 4 hours.

Correct answer: A

Rationale: Administering pain medication as prescribed is the highest priority when caring for a client with acute pancreatitis. Acute pancreatitis is often associated with severe abdominal pain, and alleviating this pain is crucial for the client's comfort and well-being. Pain management can also help reduce stress on the pancreas and promote recovery. Monitoring serum amylase and lipase levels, encouraging oral intake of clear liquids, and assessing bowel sounds are important interventions but addressing the client's pain takes precedence to provide immediate relief and improve outcomes.

3. In a patient with chronic kidney disease (CKD) receiving erythropoietin therapy, what laboratory result should the nurse monitor to evaluate the effectiveness of this therapy?

• A. Serum creatinine
• B. White blood cell count
• C. Hemoglobin level
• D. Serum potassium

Correct answer: C

Rationale: The correct answer is C: Hemoglobin level. Erythropoietin therapy is used to stimulate red blood cell production in patients with chronic kidney disease who often develop anemia due to reduced erythropoietin production by the kidneys. Monitoring the hemoglobin level is essential to evaluate the effectiveness of erythropoietin therapy as an increase in hemoglobin indicates improved red blood cell production and better management of anemia in these patients. Serum creatinine, white blood cell count, and serum potassium levels are important parameters to monitor in CKD patients but are not specific indicators of the effectiveness of erythropoietin therapy for managing anemia.

4. When assessing a client with suspected meningitis, which finding is indicative of meningeal irritation?

• A. Brudzinski's sign
• B. Positive Babinski reflex
• C. Kernig's sign
• D. Both A and C

Correct answer: D

Rationale: Both Brudzinski's sign and Kernig's sign are classic signs of meningeal irritation, commonly associated with meningitis. Brudzinski's sign is positive when flexing the neck causes involuntary flexion of the hips and knees due to irritation of the meninges. Kernig's sign is positive when there is pain and resistance with knee extension after hip flexion, indicating meningeal irritation or inflammation. The Babinski reflex, mentioned in choice B, is a test used to assess upper motor neuron damage and is not specific to meningitis. Therefore, choices A and C are the correct options as they are indicative of meningeal irritation in a suspected case of meningitis.

5. A healthcare professional is educating a group of recent nursing graduates about their risks for contracting hepatitis B. What preventative measure should the professional promote?

• A. Immunization
• B. Chronic tonsillitis
• C. Consumption of a vitamin-rich diet
• D. Annual vitamin K injections

Correct answer: A

Rationale: The correct preventative measure to promote for preventing hepatitis B infection is immunization. Healthcare workers, including nurses, are at risk of exposure to hepatitis B, and vaccination is crucial in preventing infection. Immunization, along with adherence to standard precautions such as using personal protective equipment, proper hand hygiene, and safe needle practices, plays a vital role in protecting healthcare workers from contracting hepatitis B.

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