Nursing Elites

1. A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?

• A. Increase the dosage of the medication.
• B. Auscultate bowel sounds.
• C. Monitor the client's blood pressure.
• D. Check the client's respiratory rate.

Correct answer: B

Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.

2. A client presents with three positive responses to the CAGE questionnaire. What interpretation should the nurse provide?

• A. CAGE is a tool for general substance abuse screening.
• B. Two positive responses suggest alcohol dependence.
• C. One positive response does not indicate alcohol addiction.
• D. All four responses must be positive to suggest alcohol dependence.

Correct answer: B

Rationale: Two positive responses on the CAGE questionnaire strongly suggest alcohol dependence. Choice A is incorrect as the CAGE questionnaire specifically targets alcohol abuse. Choice C is incorrect because one positive response is not enough to indicate alcohol addiction. Choice D is incorrect because alcohol dependence can be suggested with two positive responses, not all four.

3. A client with hypertension has been prescribed a calcium channel blocker. What should the nurse include in the client's teaching plan?

• A. Monitor heart rate regularly
• B. Avoid potassium-rich foods
• C. Increase fluid intake to avoid dehydration
• D. Take the medication with food

Correct answer: A

Rationale: Corrected Rationale: Calcium channel blockers can cause bradycardia, so it is important for the client to monitor their heart rate regularly. This helps detect any significant changes in heart rate that may require medical attention. Choice B is incorrect because there is no need to avoid potassium-rich foods with calcium channel blockers. Choice C is incorrect as increasing fluid intake is not specifically related to calcium channel blockers. Choice D is incorrect as calcium channel blockers are usually taken with or without food, depending on the specific medication, but not specifically on an empty stomach.

4. An adolescent client with intellectual disability refuses oral hygiene. A behavior modification program is recommended. Which reinforcement is best for the nurse to implement?

• A. Candy for successful oral hygiene tasks.
• B. Tokens for each successful oral hygiene task.
• C. Privilege restrictions for refusing oral hygiene tasks.
• D. Preferred activities or privileges for compliance.

Correct answer: D

Rationale: In this scenario, the best reinforcement for the nurse to implement is preferred activities or privileges for compliance. Positive reinforcement with privileges is effective in encouraging behavior change in adolescents, including those with intellectual disabilities. Choice A (Candy for successful oral hygiene tasks) may not be suitable as it involves providing a sugary reward, which contradicts the goal of oral hygiene. Choice B (Tokens for each successful oral hygiene task) could be effective but may not be as motivating as preferred activities or privileges. Choice C (Privilege restrictions for refusing oral hygiene tasks) focuses on negative reinforcement, which is not as effective as positive reinforcement in behavior modification.

5. A nurse is performing CPR on an adult who went into cardiopulmonary arrest. Another nurse enters the room in response to the call. After checking the client's pulse and respirations, what should be the function of the second nurse?

• A. Relieve the nurse performing CPR
• B. Go get the code cart
• C. Participate with the compressions or breathing
• D. Validate the client's advanced directive

Correct answer: C

Rationale: The correct answer is C. The second nurse should assist with compressions or breathing to ensure the patient receives adequate care during CPR. This immediate intervention is crucial in maintaining blood circulation and oxygenation to vital organs. Choice A is incorrect because simply relieving the nurse performing CPR may lead to a delay in essential life-saving measures. Choice B is incorrect as the primary focus should be on providing direct assistance rather than fetching equipment. Choice D is incorrect as validating the client's advanced directive is not the priority in this emergency situation.

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