Nursing Elites

1. A client with terminal cancer is experiencing severe pain. The nurse plans to implement which of the following pain management strategies?

• A. Administer analgesics on a fixed schedule
• B. Administer analgesics only when the client requests
• C. Use non-pharmacological methods only
• D. Increase the dose of analgesics when the client complains of pain

Correct answer: A

Rationale: Administering analgesics on a fixed schedule is the most appropriate pain management strategy for a client with terminal cancer experiencing severe pain. This approach ensures consistent pain control and helps prevent breakthrough pain. Administering analgesics only when the client requests (Choice B) may lead to uncontrolled pain as the client may delay requesting medication until the pain becomes unbearable. Using non-pharmacological methods only (Choice C) may not provide adequate pain relief for a client experiencing severe pain. Increasing the dose of analgesics when the client complains of pain (Choice D) may result in inconsistent pain control and could lead to potential overdose or adverse effects.

2. An activity designed to diagnose and treat a disease or condition in its earliest stages, before it becomes full-blown, would be classified as:

• A. primary prevention
• B. secondary prevention
• C. tertiary prevention
• D. health education

Correct answer: B

Rationale: The correct answer is B, secondary prevention. Secondary prevention focuses on early diagnosis and intervention to prevent the progression of a disease or condition. This involves detecting and treating the illness in its early stages to reduce its impact. Choice A, primary prevention, aims to prevent the development of a disease or injury before it occurs by promoting healthy behaviors. Choice C, tertiary prevention, involves managing and improving the quality of life of individuals with established conditions to prevent complications and further deterioration. Choice D, health education, refers to providing information and promoting awareness about health issues to enable individuals to make informed decisions and adopt healthy behaviors.

3. The nurse is caring for a 75-year-old client in congestive heart failure. Which finding suggests that digitalis levels should be reviewed?

• A. Extreme fatigue
• B. Increased appetite
• C. Intense itching
• D. Constipation

Correct answer: A

Rationale: Extreme fatigue can be a sign of digitalis toxicity, especially in older adults, and warrants a review of the client's medication levels and potential adjustment. Increased appetite, intense itching, and constipation are not typically associated with digitalis toxicity and do not directly indicate a need for a review of digitalis levels.

4. The nurse is caring for a client on mechanical ventilation. When performing endotracheal suctioning, the nurse will avoid hypoxia by

• A. Inserting a fenestrated catheter with a whistle tip without suction
• B. Completing the suction pass in 30 seconds with a pressure of 150 mm Hg
• C. Hyperoxygenating with 100% O2 for 1 to 2 minutes before and after each suction pass
• D. Minimizing the suction pass to 60 seconds while slowly rotating the lubricated catheter

Correct answer: C

Rationale: Hyperoxygenating the client before and after suctioning helps prevent hypoxia by ensuring adequate oxygen levels during the procedure, which briefly interrupts the client's normal breathing pattern. Choice A is incorrect because inserting a fenestrated catheter with a whistle tip without suction would not prevent hypoxia. Choice B is incorrect as completing the suction pass in 30 seconds with a pressure of 150 mm Hg may lead to hypoxia. Choice D is incorrect as minimizing the suction pass to 60 seconds may not provide enough time for effective suctioning and could lead to hypoxia.

5. Which of the following is designed to help clients reduce the risk of illness and maintain the maximum level of function?

• A. illness prevention
• B. crisis intervention
• C. rehabilitation
• D. health promotion

Correct answer: D

Rationale: The correct answer is 'D: health promotion.' Health promotion strategies are aimed at helping individuals reduce the risk of illness and maintain their maximum level of function by emphasizing preventive measures, healthy behaviors, and lifestyle choices. Illness prevention (choice A) focuses on specific actions to avoid illness but may not necessarily address overall function. Crisis intervention (choice B) refers to immediate assistance during emergencies rather than long-term prevention. Rehabilitation (choice C) involves restoring function after illness or injury rather than primarily focusing on preventive measures and maintaining maximum function.

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