Nursing Elites

1. A nurse is caring for a client who is 1 day postoperative following a total knee replacement. The client reports pain of 8 on a scale of 0 to 10. Which of the following actions should the nurse take?

• A. Administer ibuprofen 400 mg PO
• B. Administer oxycodone 10 mg PO
• C. Reposition the client to the unaffected side
• D. Apply a cold compress to the affected knee

Correct answer: B

Rationale: In this scenario, the appropriate action for the nurse to take when a client reports severe postoperative pain of 8 out of 10 is to administer oxycodone 10 mg PO. Oxycodone is a potent analgesic that is more effective in managing severe pain compared to ibuprofen, making choice A incorrect. Repositioning the client to the unaffected side or applying a cold compress may provide some comfort but are not the priority interventions for severe postoperative pain, making choices C and D less appropriate.

2. A client with schizophrenia is experiencing delusions. Which of the following actions should the nurse take?

• A. Encourage the client to discuss the delusions.
• B. Tell the client that the delusions are not real.
• C. Avoid discussing the delusions with the client.
• D. Challenge the client's delusions directly.

Correct answer: B

Rationale: Telling the client that their delusions are not real is the most appropriate action as it helps ground them in reality without reinforcing the delusion. Encouraging the client to discuss the delusions (choice A) may further validate or intensify the delusions. Avoiding discussing the delusions (choice C) may lead to the client feeling isolated and unheard. Challenging the client's delusions directly (choice D) can escalate the situation and cause distress to the client.

3. When documenting an incorrect dose of medication administered, which fact related to the incident report should the nurse document in the client's medical record?

• A. Time the medication was given
• B. The client's response to the medication
• C. The dose that was administered
• D. Reason for the error

Correct answer: A

Rationale: The nurse should document the time the medication was given in the client's medical record when an incorrect dose is administered. Recording the time is crucial for establishing the sequence of events accurately. Choices B, C, and D, though important, are not directly relevant to documenting the incident of administering an incorrect dose of medication. The client's response to the medication, the actual dose administered, and the reason for the error may be documented for overall patient care but are not specifically required in the incident report for an incorrect dose.

4. When managing blood pressure at home, which statement by the client indicates an understanding of the teaching provided by a nurse for hypertension?

• A. I will take my medication only when I feel dizzy.
• B. I will check my blood pressure at least once a week.
• C. I will stop taking my medication once my blood pressure is within normal range.
• D. I will sit quietly for 5 minutes before measuring my blood pressure.

Correct answer: D

Rationale: The correct answer is D because sitting quietly for 5 minutes before measuring blood pressure ensures an accurate reading and helps monitor hypertension. Choice A is incorrect as medications for hypertension should be taken as prescribed, not based on symptoms like dizziness. Choice B is not ideal as blood pressure should be checked more frequently, preferably daily. Choice C is incorrect as stopping medication abruptly once blood pressure is normal can lead to rebound hypertension.

5. A nurse is providing discharge teaching to a client who has a new prescription for albuterol. Which of the following instructions should the nurse include?

• A. You should take this medication at bedtime.
• B. You might experience palpitations while taking this medication.
• C. You should rinse your mouth after using this medication.
• D. You should avoid eating before taking this medication.

Correct answer: C

Rationale: The correct answer is C: 'You should rinse your mouth after using this medication.' When providing discharge teaching for a client prescribed albuterol, the nurse should include the instruction to rinse the mouth after each use. This is important to prevent dry mouth and oral infections. Choice A is incorrect as albuterol is usually taken during the day to manage symptoms, not at bedtime. Choice B is incorrect as palpitations are not a common side effect of albuterol. Choice D is incorrect as there is no specific requirement to avoid eating before taking albuterol.

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