Nursing Elites

1. What is the priority assessment for a patient receiving intravenous morphine?

• A. Assessing the patient's blood pressure.
• B. Monitoring the patient's respiratory rate.
• C. Checking the patient's pain level.
• D. Monitoring the patient's oxygen saturation.

Correct answer: B

Rationale: The correct answer is monitoring the patient's respiratory rate. When a patient receives intravenous morphine, the priority assessment is to monitor the respiratory rate due to the risk of respiratory depression associated with morphine. This assessment helps in detecting and managing any potential respiratory complications promptly. Assessing blood pressure, checking pain level, and monitoring oxygen saturation are important aspects of patient care but are not the priority when considering the specific risk of respiratory depression with intravenous morphine.

2. The client with chronic renal failure is being educated on dietary restrictions. Which of the following foods should the client avoid?

• A. Bananas.
• B. Oranges.
• C. Rice.
• D. Apples.

Correct answer: A

Rationale: The correct answer is A: Bananas. Bananas are high in potassium, and clients with chronic renal failure are often advised to follow a low-potassium diet to prevent hyperkalemia. Oranges and apples are also high in potassium and should be avoided by clients with renal issues. Rice, on the other hand, is low in potassium and is generally considered safe for individuals with chronic renal failure to consume in moderation.

3. The nurse is collecting information from a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

• A. Presence and activity of bowel sounds
• B. Color and consistency of feces
• C. Eating patterns and dietary intake
• D. Level and amount of physical activity

Correct answer: C

Rationale: In chronic pancreatitis, managing abdominal pain is crucial, and assessing the client's eating patterns and dietary intake is essential. Dietary modifications can help alleviate symptoms and reduce the workload on the pancreas. Choices A, B, and D are not directly related to pain management in chronic pancreatitis. Bowel sounds, fecal characteristics, and physical activity may provide important information in other conditions but are not the priority in this scenario.

4. A client with acute glomerulonephritis (GN) is being evaluated by a nurse. Which manifestation should the nurse recognize as a positive response to the prescribed treatment?

• A. The client has lost 11 pounds in the past 10 days.
• B. The client’s urine specific gravity is 1.048.
• C. No blood is observed in the client’s urine.
• D. The client’s blood pressure is 152/88 mm Hg.

Correct answer: A

Rationale: A weight loss of 11 pounds in the past 10 days indicates fluid loss, a positive response to treatment for acute glomerulonephritis. It signifies that the glomeruli are functioning adequately to filter excess fluid. A urine specific gravity of 1.048 is high, indicating concentrated urine, which is not a positive response in this context. Blood in the urine is not a typical finding in glomerulonephritis, so its absence is expected and does not indicate a positive response to treatment. A blood pressure of 152/88 mm Hg is elevated and may suggest kidney damage or fluid overload, which are not positive responses to treatment.

5. While assessing a female client who is chronically fatigued and was recently diagnosed with adrenal insufficiency, the client tells the nurse that she is very nervous that her hospitalization will cause her to lose her job. Which intervention should the nurse implement first?

• A. Teach the client about the risk for infection.
• B. Offer support and care measures to reduce anxiety and stress.
• C. Encourage the client to rest quietly to reduce fatigue.
• D. Place a referral to social services to discuss financial options.

Correct answer: B

Rationale: In this scenario, the priority intervention for the nurse is to offer support and care measures to reduce anxiety and stress. Addressing the client's emotional distress is crucial as the stress can exacerbate adrenal insufficiency. While teaching the client about the risk for infection (Choice A) is important, addressing the immediate emotional needs takes precedence. Encouraging the client to rest quietly (Choice C) is beneficial but does not directly address the client's current distress about job loss. Referring the client to social services (Choice D) for financial options is important, but at this moment, addressing the client's anxiety is the priority to promote emotional well-being.

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