Nursing Elites

1. A nurse is assessing a client who is experiencing acute pain. Which of the following manifestations should the nurse expect?

• A. Hypertension
• B. Bradycardia
• C. Diaphoresis
• D. Piloerection

Correct answer: C

Rationale: The correct answer is C: Diaphoresis. Diaphoresis, which is excessive sweating, is a common manifestation of acute pain caused by increased sympathetic nervous system activity. This response is the body's way of trying to regulate body temperature during the stress response. Choices A, B, and D are incorrect. Hypertension (Choice A) and tachycardia (not bradycardia as in Choice B) are more likely responses to acute pain due to sympathetic nervous system activation. Piloerection (Choice D), also known as goosebumps, is not a typical manifestation of acute pain.

2. What is the appropriate action when a patient presents with chest pain?

• A. Administer aspirin
• B. Administer nitroglycerin
• C. Reposition the patient
• D. Prepare for surgery

Correct answer: A

Rationale: The appropriate action when a patient presents with chest pain is to administer aspirin. Aspirin helps reduce the risk of clot formation by inhibiting platelet aggregation, which can be beneficial in cases of myocardial infarction. Nitroglycerin is commonly used for chest pain related to angina but is not the first-line treatment for all types of chest pain. Repositioning the patient may be necessary for comfort or assessment but is not the immediate priority. Surgery is not typically the first-line intervention for chest pain unless there are specific indications.

3. A nurse is planning care for a client who has Alzheimer's disease and demonstrates confusion and wandering behavior. Which of the following should the nurse include in the plan of care?

• A. Place the client in seclusion when she is confused.
• B. Request a prescription for PRN restraints when the client is wandering.
• C. Dim the lighting in the client's room.
• D. Leave one side rail up on the client's bed.

Correct answer: C

Rationale: The correct answer is to dim the lighting in the client's room. Dim lighting can help reduce confusion and agitation in clients with Alzheimer's disease. Placing the client in seclusion (Choice A) is not recommended as it can lead to feelings of isolation and distress. Requesting PRN restraints (Choice B) should be avoided in clients with Alzheimer's as it can increase agitation and pose safety risks. Leaving one side rail up on the client's bed (Choice D) may not directly address the client's confusion and wandering behavior.

4. Which medication is commonly prescribed for a patient with a history of heart failure?

• A. Furosemide
• B. Metoprolol
• C. Digoxin
• D. Aspirin

Correct answer: A

Rationale: Furosemide is the correct answer. It is a common diuretic used in patients with heart failure to reduce fluid overload. Metoprolol (Choice B) is a beta-blocker often prescribed to manage heart failure symptoms by improving heart function. Digoxin (Choice C) is used in heart failure patients to help the heart beat stronger and with a more regular rhythm. Aspirin (Choice D) is not typically prescribed for heart failure but may be used in patients with heart disease for its antiplatelet effects.

5. A nurse is providing teaching about gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse give?

• A. Administer the feeding over 30 minutes
• B. Place the child in a supine position after the feeding
• C. Change the feeding bag and tubing every 3 days
• D. Warm the formula in the microwave prior to administration

Correct answer: A

Rationale: The correct answer is to administer the feeding over 30 minutes. This slow administration helps prevent complications like nausea. Placing the child in a supine position after the feeding can increase the risk of aspiration, making choice B incorrect. Changing the feeding bag and tubing every 3 days is important for infection control and hygiene but is not directly related to the administration process, making choice C incorrect. Warming the formula in the microwave is not recommended as it can create hot spots that may burn the child's mouth or esophagus, so choice D is incorrect.

Similar Questions