Nursing Elites

1. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?

• A. Amount of support provided by family members
• B. Measurement of pain using a scale of 0 to 10
• C. The ability to perform ADLs
• D. Nonverbal behaviors exhibited when pain occurs

Correct answer: C

Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs. While family support, pain measurement, and nonverbal behaviors are important aspects to consider in caring for a client with chronic pain, the ability to perform ADLs directly reflects the client's independence and quality of life, making it the most crucial information to obtain.

2. During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?

• A. Between the vaginal orifice and the anus.
• B. Between the clitoris and the vaginal orifice.
• C. Just above the clitoris.
• D. Within the vaginal canal.

Correct answer: B

Rationale: The correct location of the urethral meatus in females is between the clitoris and the vaginal orifice. When performing a urethral catheterization, it is crucial to identify this anatomical landmark for correct insertion of the catheter. Choice A is incorrect as the urethral meatus is not located between the vaginal orifice and the anus. Choice C is incorrect as the urethral meatus is not located just above the clitoris. Choice D is incorrect as the urethral meatus is not within the vaginal canal.

3. Which serum laboratory value should the nurse monitor carefully for a client who has had an NG tube for suctioning for the past week?

• A. White blood cell count
• B. Albumin
• C. Calcium
• D. Sodium

Correct answer: D

Rationale: The nurse should carefully monitor serum sodium levels for a client with an NG tube on suction for an extended period due to potential fluid loss and the risk of developing hyponatremia, an electrolyte imbalance. Hyponatremia can occur as a result of continual suctioning leading to fluid loss, making it crucial to monitor sodium levels to prevent complications associated with low sodium levels. Monitoring white blood cell count, albumin, or calcium is not directly related to the impact of NG tube suction on fluid and electrolyte balance, so these values are not the priority in this scenario.

4. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

• A. Blood glucose level of 150 mg/dL.
• B. Blood pressure of 110/70 mm Hg.
• C. Serum albumin level of 3.5 g/dL.
• D. The client's temperature is 100.4°F (38°C).

Correct answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

5. A postoperative client has three different PRN analgesics prescribed for varying levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?

• A. Assess for side effects of the medication.
• B. Document the client’s responses.
• C. Complete a medication error report.
• D. Determine if the pain was relieved.

Correct answer: A

Rationale: In the scenario where a nurse administers a medication outside the prescribed parameters, the immediate action should be to assess the client for any potential side effects of the medication. This is crucial to ensure the client's safety and well-being. By promptly assessing for side effects, the nurse can address any adverse reactions promptly and provide necessary interventions. Once the client's safety is ensured, documenting the client's responses, completing a medication error report, and assessing pain relief can follow as part of the broader response to the medication error. Choice B is not the first priority because the immediate concern is the potential harm from the incorrect dose. Choice C is also important but comes after ensuring the client's safety. Choice D focuses on the outcome rather than the immediate need to address any side effects of the medication.

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