Nursing Elites

1. The client is receiving intravenous (IV) morphine for pain control. Which assessment finding requires the most immediate intervention?

• A. Drowsiness.
• B. Itching.
• C. Nausea.
• D. Respiratory rate of 8 breaths per minute.

Correct answer: D

Rationale: A respiratory rate of 8 breaths per minute indicates severe respiratory depression, a life-threatening side effect of opioid therapy. Immediate intervention is crucial to prevent respiratory failure. Monitoring and managing respiratory status are critical in clients receiving opioids to prevent adverse events. Drowsiness, itching, and nausea are common side effects of morphine but are not as immediately life-threatening as severe respiratory depression.

2. A 65-year-old man presents with weight loss, jaundice, and a palpable mass in the right upper quadrant. Laboratory tests reveal elevated bilirubin and alkaline phosphatase levels. What is the most likely diagnosis?

• A. Gallstones
• B. Hepatitis
• C. Pancreatic cancer
• D. Primary biliary cirrhosis

Correct answer: C

Rationale: The combination of weight loss, jaundice, a palpable mass in the right upper quadrant, and elevated bilirubin and alkaline phosphatase levels strongly suggests pancreatic cancer. The presentation is classic for pancreatic malignancy, which commonly presents with obstructive jaundice due to the tumor blocking the common bile duct, leading to elevated bilirubin and alkaline phosphatase levels. Weight loss is a common symptom of advanced pancreatic cancer. The palpable mass in the right upper quadrant corresponds to the location of the pancreas. Gallstones typically manifest with different symptoms, while hepatitis and primary biliary cirrhosis are less likely to present with a palpable mass and weight loss in this scenario.

3. During a home visit, the nurse should evaluate the adequacy of a client's COPD treatment by assessing for which primary symptom?

• A. Dyspnea
• B. Tachycardia
• C. Unilateral diminished breath sounds
• D. Edema of the ankles

Correct answer: A

Rationale: Assessing for dyspnea is crucial when evaluating COPD treatment effectiveness as it is a primary symptom of the condition. Dyspnea, or difficulty breathing, is a common and distressing symptom in COPD patients. Monitoring the severity of dyspnea can provide valuable insights into the client's response to treatment and disease progression.

4. A 60-year-old male client is admitted to the hospital with the complaint of right knee pain for the past week. His right knee and calf are warm and edematous. He has a history of diabetes and arthritis. Which neurological assessment action should the nurse perform for this client?

• A. Glasgow Coma Scale
• B. Assess pulses, paresthesia, and paralysis distal to the right knee
• C. Assess pulses, paresthesia, and paralysis proximal to the right knee
• D. Optic nerve using an ophthalmoscope

Correct answer: B

Rationale: In this scenario, the nurse should assess pulses, paresthesia, and paralysis distal to the right knee to evaluate for neurovascular compromise. This assessment helps determine the perfusion and sensation of the lower extremity, which is crucial in identifying potential vascular or nerve damage that may be causing the client's symptoms.

5. A 45-year-old man with a history of chronic heartburn presents with progressive difficulty swallowing solids and liquids. He has lost 10 pounds in the past two months. What is the most likely diagnosis?

• A. Esophageal stricture
• B. Esophageal cancer
• C. Achalasia
• D. Peptic ulcer disease

Correct answer: B

Rationale: In this scenario, the patient's presentation of progressive dysphagia to both solids and liquids, along with significant weight loss, is concerning for esophageal cancer. The history of chronic heartburn further raises suspicion as chronic gastroesophageal reflux disease is a risk factor for the development of esophageal adenocarcinoma. Esophageal stricture could cause dysphagia but is less likely to be associated with significant weight loss. Achalasia typically presents with dysphagia to solids more than liquids and does not commonly cause weight loss. Peptic ulcer disease is less likely to lead to progressive dysphagia and significant weight loss compared to esophageal cancer.

Similar Questions