Nursing Elites

1. The healthcare provider is assessing a client who has just undergone a thoracentesis. Which finding should be reported immediately?

• A. Diminished breath sounds on the affected side.
• B. Pain at the procedure site.
• C. Blood-tinged sputum.
• D. Shortness of breath.

Correct answer: D

Rationale: Shortness of breath should be reported immediately as it may indicate a pneumothorax, a potential complication of thoracentesis. Diminished breath sounds on the affected side, pain at the procedure site, and blood-tinged sputum are common findings post-thoracentesis and do not necessarily indicate immediate complications like a pneumothorax.

2. The nurse is caring for a client who has just returned from surgery with an indwelling urinary catheter in place. What is the most important assessment for the nurse to make?

• A. Check for catheter patency
• B. Assess the color of the urine
• C. Measure the urine output
• D. Ensure the catheter tubing is secure

Correct answer: C

Rationale: The most important assessment for the nurse to make in this situation is to measure the urine output. This assessment is crucial in monitoring kidney function and fluid balance after surgery. While checking for catheter patency is important, it is not as critical as measuring urine output. Assessing the color of the urine can provide some information about kidney function, but measuring output gives a more accurate assessment. Ensuring the catheter tubing is secure is essential to prevent dislodgement but is not the most critical assessment to make at this time.

3. A client is receiving morphine for pain management. What is the most important assessment for the nurse to perform?

• A. Check the client's respiratory rate
• B. Assess the client's pain level
• C. Monitor the client's blood pressure
• D. Evaluate the client's level of consciousness

Correct answer: A

Rationale: The correct answer is to check the client's respiratory rate. Morphine can lead to respiratory depression, which makes it crucial for the nurse to monitor the client's breathing closely. Assessing the respiratory rate helps in early detection of potential respiratory depression and allows prompt intervention. While assessing pain level (choice B) is important, monitoring the respiratory status takes precedence due to the risk of respiratory depression with morphine. Monitoring blood pressure (choice C) is relevant but not as crucial as assessing respiratory status in a client receiving morphine. Evaluating the level of consciousness (choice D) is also important but does not directly address the immediate risk associated with morphine administration.

4. A client with asthma is prescribed a corticosteroid inhaler. What instruction should the nurse give about the inhaler?

• A. Use it only during asthma attacks
• B. Rinse the mouth after each use to prevent oral thrush
• C. It will provide immediate relief during an asthma attack
• D. Increase the dose if breathing does not improve

Correct answer: B

Rationale: The correct instruction for a client using a corticosteroid inhaler is to rinse the mouth after each use to prevent the development of oral thrush, a common side effect of these inhalers. Choice A is incorrect as corticosteroid inhalers are often used regularly as a maintenance treatment, not just during asthma attacks. Choice C is incorrect because corticosteroid inhalers provide long-term control of asthma symptoms, not immediate relief during an attack. Choice D is incorrect and potentially dangerous advice as increasing the dose without medical guidance can lead to adverse effects.

5. Which membrane lines the abdominal cavity?

• A. Perineum
• B. Pericardium
• C. Pleura
• D. Peritoneum

Correct answer: D

Rationale: The correct answer is D, Peritoneum. The peritoneum is the membrane that lines the abdominal cavity, providing support to abdominal organs and serving as a conduit for their blood vessels. Choices A, B, and C are incorrect. The perineum refers to the area between the anus and the external genitalia, the pericardium is the membrane enclosing the heart, and the pleura is the membrane surrounding the lungs.

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