Nursing Elites

1. The nurse is evaluating a client who had a cardiac catheterization with a left antecubital insertion site. Which of the following pulses should the nurse palpate?

• A. Brachial pulse in the right arm
• B. Radial pulse in the right arm
• C. Brachial pulse in the left arm
• D. Radial pulse in the left arm

Correct answer: D

Rationale: The correct answer is to palpate the radial pulse in the left arm. When the antecubital insertion site is on the left side, it is important to assess the radial pulse on the same side to monitor circulation accurately. Palpating the brachial pulse in the right or left arm or the radial pulse in the right arm would not provide direct information about the circulation related to the catheterization site.

2. A patient is admitted with suspected pneumonia. What is the nurse's priority assessment?

• A. Auscultate the patient's lung sounds.
• B. Assess the patient's oxygen saturation.
• C. Monitor the patient's white blood cell count.
• D. Monitor the patient's skin integrity.

Correct answer: B

Rationale: The correct answer is to assess the patient's oxygen saturation. In suspected pneumonia, ensuring adequate oxygenation is critical to monitor respiratory function. Auscultating lung sounds is important but assessing oxygen saturation takes precedence as it directly reflects the patient's oxygen levels. Monitoring white blood cell count is more related to infection assessment rather than immediate respiratory status. Checking skin integrity is essential for overall patient care but is not the priority in a patient with suspected pneumonia.

3. When assessing a client with terminal cancer receiving a continuous intravenous infusion of morphine sulfate, what should the nurse check first?

• A. Check for respiratory depression.
• B. Assess pain control.
• C. Check the infusion site for complications.
• D. Monitor the client's blood pressure.

Correct answer: A

Rationale: The correct answer is to check for respiratory depression first when assessing a client receiving a continuous intravenous infusion of morphine sulfate. Respiratory depression is the most common life-threatening side effect associated with morphine administration. Monitoring respiratory status is crucial as it can quickly deteriorate, leading to serious complications or even respiratory arrest. Assessing pain control (choice B) is important but ensuring adequate ventilation takes precedence. Checking the infusion site for complications (choice C) and monitoring blood pressure (choice D) are also essential aspects of care but are secondary to evaluating respiratory status when administering morphine.

4. A patient is admitted with signs of stroke. Which of the following diagnostic tests should the nurse anticipate as the priority?

• A. CT scan
• B. MRI
• C. X-ray
• D. Ultrasound

Correct answer: A

Rationale: A CT scan is the priority diagnostic test to identify and confirm the location and severity of a stroke.

5. A healthcare professional is assessing a patient's fluid balance. What is the most reliable indicator of fluid status?

• A. Monitor the patient's vital signs.
• B. Check the patient's weight daily.
• C. Measure the patient's intake and output.
• D. Monitor the patient's urine color.

Correct answer: B

Rationale: Checking the patient's weight daily is the most reliable indicator of fluid status because weight changes can directly reflect fluid retention or loss. Monitoring vital signs (Choice A) can provide some information but is not as specific as weight changes. Measuring intake and output (Choice C) is crucial but may not always accurately reflect fluid balance. Monitoring urine color (Choice D) can give some insights into hydration levels, but it is not as reliable as daily weight checks for assessing overall fluid status.

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