Nursing Elites

1. When managing nausea related to Morphine epidural analgesia, the nurse should administer:

• A. Indomethacin
• B. Codeine
• C. Ibuprofen
• D. Compazine

Correct answer: D

Rationale: When managing nausea related to Morphine epidural analgesia, Compazine is the appropriate medication to administer. Compazine, also known as prochlorperazine, is commonly used to treat nausea and vomiting. It works by affecting certain chemicals in the brain that trigger nausea and vomiting. Choices A, B, and C are incorrect because Indomethacin, Codeine, and Ibuprofen are not typically used to manage nausea associated with Morphine epidural analgesia.

2. Which of the following nursing diagnoses is most appropriate for a client with a new colostomy?

• A. Excess Fluid Volume
• B. Risk for Aspiration
• C. Disturbed Body Image
• D. Urinary Retention

Correct answer: C

Rationale: Disturbed Body Image is the most appropriate nursing diagnosis for a client with a new colostomy. A new colostomy can significantly impact a person's body image and self-esteem due to the physical changes it brings. This can lead to emotional distress, adjustment issues, and concerns about body image. Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are not directly related to the psychosocial impact of a new colostomy and are therefore not as relevant in this context. While Excess Fluid Volume, Risk for Aspiration, and Urinary Retention are important nursing diagnoses, they are not the priority when considering the psychological and emotional effects of a new colostomy.

3. Which of the following statements from a client may indicate that they are at a higher risk for a fall?

• A. "I would like to get out of bed but would like to put on my non-skid socks first."?
• B. "Can you make sure the two bedrails are raised before leaving the room?"?
• C. "I think I'm ready to walk a longer distance with the cane today."?
• D. "I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait."?

Correct answer: D

Rationale: The correct answer is 'I need to get out of bed to go to the bathroom now. I cannot find my glasses but cannot wait.' This statement indicates that the client is in a hurry and unable to find their glasses, which could increase the risk of a fall due to impaired vision. Choice A about putting on non-skid socks shows the client's awareness of fall prevention, reducing the risk. Choice B demonstrates the client's request for bedrails to be raised, which is a safety measure, reducing the risk as well. Choice C suggests the client's readiness to walk a longer distance with a cane, indicating progress in mobility but not necessarily a higher fall risk.

4. A nurse in a long-term care center notes that an employee is constantly calling in sick. Which action should the nurse take initially to handle this problem?

• A. Documenting the employee's absences in the personnel file
• B. Discussing the situation with the employee and reminding them of the agency's employment standards
• C. Reporting the employee to administration
• D. Issuing a written warning to the employee

Correct answer: B

Rationale: When an employee demonstrates excessive absenteeism, the initial action a nurse should take is to discuss the situation with the employee and remind them of the agency's employment standards. It is important to communicate openly with the employee to understand the reasons for their frequent absences and remind them of the expectations regarding attendance. This approach allows for a constructive dialogue and provides the employee with an opportunity to rectify their behavior. Documenting the employee's absences in the personnel file may be necessary if the issue persists despite the discussion. Reporting the employee to administration should be considered only if the employee fails to improve after the initial discussion. Issuing a written warning should be a subsequent step if the employee continues to violate the attendance policies even after reminders and discussions.

5. A nursing care plan for a client with sleep problems has been implemented. All of the following should be expected outcomes except:

• A. the client reports no episodes of awakening during the night.
• B. the client falls asleep within 1 hour of going to bed.
• C. the client reports satisfaction with their amount of sleep.
• D. the client rates sleep as an 8 or more on the visual analog scale.

Correct answer: B

Rationale: An expected outcome for a nursing care plan targeting sleep problems is that the client reports no episodes of awakening during the night, the client reports satisfaction with their amount of sleep, and the client rates sleep as an 8 or more on the visual analog scale. Falling asleep within 1 hour of going to bed is not necessarily an expected outcome. While it is generally desirable for individuals to fall asleep within a reasonable time frame, this specific timeframe may vary among individuals, and it is not a strict criterion for successful sleep outcomes. Therefore, the correct answer is that the client falls asleep within 1 hour of going to bed, as this is not a definitive measure of the effectiveness of the nursing care plan for sleep problems.

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