Nursing Elites

1. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

• A. Use the Wong-Baker Faces pain rating scale
• B. Assess vital signs to gauge pain severity
• C. Ask the client to describe the pain
• D. Offer a 1-10 pain scale

Correct answer: C

Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.

2. The nurse is preparing an older adult for discharge following cataract extraction. What is the most important instruction?

• A. Avoid straining, bending, or lifting heavy objects.
• B. Limit exposure to sunlight for the first 2 weeks.
• C. Use direct lighting when reading for 6 weeks.
• D. Irrigate the conjunctiva with saline before applying ointment.

Correct answer: A

Rationale: The most important instruction for a patient following cataract extraction is to avoid straining, bending, or lifting heavy objects. These activities can increase intraocular pressure and potentially lead to complications such as bleeding or dislocation of the intraocular lens. Choices B, C, and D are not as critical in the immediate post-operative period. Limiting sunlight exposure and using direct lighting when reading are important but not as crucial as avoiding activities that can increase intraocular pressure. Irrigating the conjunctiva with saline before applying ointment is not a standard post-cataract surgery instruction.

3. The nurse is providing care for a client with a percutaneous endoscopic gastrostomy (PEG) tube. Which intervention should the nurse implement to prevent complications associated with the tube?

• A. Elevate the head of the bed to 15 degrees during feedings
• B. Aspirate gastric contents before administering medications
• C. Clamp the tube between feedings
• D. Flush the tube with water before and after feedings

Correct answer: D

Rationale: Flushing the PEG tube with water before and after feedings helps prevent clogging and maintains tube patency. Proper flushing is essential for avoiding complications related to tube blockages. Elevating the head of the bed is important for preventing aspiration during and after feedings, not specifically related to PEG tube complications. Aspirating gastric contents before administering medications is not routinely recommended for PEG tube care. Clamping the tube between feedings can lead to tube occlusion and is not a standard practice in PEG tube care.

4. After a lumbar puncture, a client reports a severe headache. What is the nurse's priority intervention?

• A. Administer a dose of acetaminophen.
• B. Elevate the head of the bed.
• C. Encourage the client to rest in a dark room.
• D. Administer caffeine to relieve the headache.

Correct answer: B

Rationale: After a lumbar puncture, a severe headache is often caused by cerebrospinal fluid leakage. Elevating the head of the bed or having the client lie flat can reduce cerebrospinal fluid pressure and alleviate the headache. These positions help prevent further fluid loss and relieve discomfort. While acetaminophen or caffeine may help in relieving the headache, changing the client's position is the priority to address the underlying cause. Resting in a dark room may be beneficial for headache relief but is not the priority intervention compared to adjusting the position to manage cerebrospinal fluid pressure.

5. A client with heart failure reports nausea, vomiting, yellow vision, and palpitations. What should the nurse assess first?

• A. Administer antiemetics to reduce nausea.
• B. Obtain a list of the client's cardiac medications.
• C. Perform an ECG to evaluate heart function.
• D. Review the client's dietary intake for possible causes.

Correct answer: B

Rationale: The combination of nausea, vomiting, yellow vision, and palpitations in a heart failure patient is indicative of digoxin toxicity. The nurse should first obtain a list of the client's medications to verify if they are taking digoxin.

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