Nursing Elites

1. Prior to administering morphine sulfate (Morphine), the nurse takes the client's vital signs. Based on which finding should the nurse withhold administration of the medication until the charge nurse is notified?

• A. Temperature of 100.8°F
• B. A pulse rate of 150 beats per minute
• C. A respiratory rate of 10 breaths per minute
• D. A blood pressure of 180/110

Correct answer: C

Rationale: The correct answer is C because a low respiratory rate is a critical concern when administering opioids like morphine, as they can suppress breathing. A high pulse rate (choice B) and high blood pressure (choice D) are not immediate contraindications for administering morphine. A slightly elevated temperature (choice A) may not necessarily require withholding morphine.

2. A client with pneumonia is experiencing difficulty expectorating thick secretions. What intervention should the nurse implement to assist the client?

• A. Administer antibiotics as prescribed
• B. Perform chest physiotherapy
• C. Encourage increased fluid intake
• D. Provide humidified oxygen

Correct answer: C

Rationale: The correct intervention for a client experiencing difficulty expectorating thick secretions due to pneumonia is to encourage increased fluid intake. Increasing fluid intake helps to thin secretions, making them easier to expectorate. Administering antibiotics (Choice A) is important in treating pneumonia but does not directly address the issue of thick secretions. Chest physiotherapy (Choice B) may help in some cases, but increasing fluid intake is a more straightforward and effective intervention. Providing humidified oxygen (Choice D) can help with oxygenation but does not directly address the problem of thick secretions.

3. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's priority action?

• A. Continue the transfusion at a slower rate
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: When a client receiving a blood transfusion reports chills and back pain, it indicates a possible transfusion reaction. The nurse's priority action is to stop the transfusion immediately. Continuing the transfusion at a slower rate (Choice A) can exacerbate the reaction. Administering an antipyretic (Choice B) may help with fever but does not address the underlying issue of a transfusion reaction. Notifying the healthcare provider (Choice D) is important but should not delay the immediate action of stopping the transfusion to ensure the client's safety.

4. The nurse is caring for a client who has just received a blood transfusion. The client reports chills and back pain. What is the nurse's priority action?

• A. Slow down the rate of the transfusion
• B. Administer an antipyretic
• C. Stop the transfusion immediately
• D. Notify the healthcare provider

Correct answer: C

Rationale: Chills and back pain are signs of a possible transfusion reaction, which can indicate severe complications like a hemolytic reaction or sepsis. The priority action for the nurse is to stop the transfusion immediately to prevent further harm to the client. Slowing the rate of the transfusion or administering an antipyretic will not address the underlying cause of the reaction and could potentially worsen the client's condition. Notifying the healthcare provider should be done after ensuring the client's immediate safety by stopping the transfusion.

5. How should the nurse assess for cyanosis in a client with dark skin who is in respiratory distress?

• A. Abnormal skin color changes in a client with dark skin cannot be determined
• B. Blanching the soles of the feet in a client with dark skin reveals cyanosis
• C. The lips and mucus membranes of a client with dark skin are dusky in color
• D. Cyanosis in a client with dark skin is seen in the sclera

Correct answer: C

Rationale: Observing the lips and mucous membranes provides a reliable indicator of cyanosis in clients with dark skin tones. Choice A is incorrect because cyanosis can be assessed in clients with dark skin by observing other body areas. Choice B is incorrect as blanching the soles of the feet is not a relevant method for assessing cyanosis. Choice D is incorrect as cyanosis is not typically seen in the sclera in clients with dark skin.

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