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 healthcare provider assesses a client with cirrhosis and finds 4+ pitting edema of the feet and legs, and massive ascites. Which mechanism contributes to edema and ascites in clients with cirrhosis?

• A. Hyperaldosteronism causing increased sodium transport ion in renal tubules
• B. Decreased portacaval pressure with greater collateral circulation
• C. Decreased renin-angiotensin response related to increased renal blood flow
• D. Hypoalbuminemia that results in decreased colloidal oncotic pressure

Correct answer: D

Rationale: In clients with cirrhosis, hypoalbuminemia leads to decreased colloidal oncotic pressure. This reduction in oncotic pressure contributes to the development of edema in the feet and legs (pitting edema) and ascites in the abdomen. Hyperaldosteronism (choice A) would lead to sodium retention but is not the primary mechanism behind edema and ascites in cirrhosis. Decreased portacaval pressure with greater collateral circulation (choice B) is not directly related to the pathophysiology of edema and ascites in cirrhosis. Decreased renin-angiotensin response related to increased renal blood flow (choice C) does not play a significant role in the development of edema and ascites in cirrhosis compared to the impact of hypoalbuminemia on colloidal oncotic pressure.

3. A client with stress incontinence is being taught about pelvic muscle exercises. Which statements should be included by the nurse? (Select all that apply.)

• A. Starting and stopping the urine stream involves using pelvic muscles.
• B. Tighten pelvic muscles for a slow count of 10 and then relax for a slow count of 10.
• C. Pelvic muscle exercises can be performed in various positions: lying down, sitting up, and standing.
• D. A & B

Correct answer: D

Rationale: The correct statements to include when teaching a client with stress incontinence about pelvic muscle exercises are that starting and stopping the urine stream involve using pelvic muscles and that tightening pelvic muscles for a slow count of 10 and then relaxing for a slow count of 10 can help strengthen them. It is essential to highlight that pelvic muscle exercises can be performed in various positions, including lying down, sitting up, and standing. This variety in positions helps engage the muscles effectively. Performing these exercises 15 times in each position can aid in strengthening the pelvic floor muscles. Consistent exercise over several weeks typically leads to improved control over urine leakage. Choice C is incorrect because pelvic muscle exercises can be performed in different positions and are not limited to sitting upright with feet on the floor.

4. A nurse has a prescription to discontinue a client’s nasogastric tube. The nurse auscultates the client’s bowel sounds, positions the client properly, and flushes the tube with 15 mL of air to clear secretions. The nurse then instructs the client to take a deep breath and:

• A. Exhale during tube removal
• B. Bear down during tube removal
• C. Hold the breath during tube removal
• D. Breathe normally during tube removal

Correct answer: C

Rationale: The correct answer is to instruct the client to hold their breath during tube removal. This is because the airway may be temporarily obstructed during the removal process. By holding their breath, the client can help prevent aspiration or discomfort during the removal of the nasogastric tube. Choices A, B, and D are incorrect because exhaling, bearing down, or breathing normally during tube removal may not provide the necessary protection against aspiration or discomfort that holding the breath does.

5. A healthcare professional is reading the chest x-ray report of a client who has just been intubated. The report states that the tip of the endotracheal tube lies 1 cm above the carina. The healthcare professional interprets that the tube is positioned above:

• A. The first tracheal cartilaginous ring
• B. The point where the larynx connects to the trachea
• C. The bifurcation of the right and left main stem bronchi
• D. The area connecting the oropharynx to the laryngopharynx

Correct answer: C

Rationale: The carina is a cartilaginous ridge that separates the openings of the two main stem (right and left) bronchi. If an endotracheal tube is inserted past the carina, the tube will enter the right main stem bronchus due to the natural curvature of the airway. This positioning is dangerous as only the right lung will be ventilated. It can be identified as only the right lung will have breath sounds and rise and fall with ventilation. Choices A, B, and D are incorrect as they do not relate to the specific anatomical landmark mentioned in the scenario.

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