Nursing Elites

1. A client postoperative expresses pain during dressing changes. What should the nurse prioritize?

• A. Administer pain medication 45 minutes before changing the client’s dressing.
• B. Change the dressing less frequently.
• C. Apply a topical anesthetic before removing the dressing.
• D. Use a non-adherent dressing to reduce pain.

Correct answer: A

Rationale: Administering pain medication before changing the dressing is the priority action as it will help alleviate the client's pain and improve comfort. Choice B, changing the dressing less frequently, may hinder proper wound care and healing. Applying a topical anesthetic (choice C) might offer some relief but systemic pain medication is more effective. Using a non-adherent dressing (choice D) can reduce pain during dressing changes, but addressing immediate pain with medication is the most appropriate intervention in this case.

2. After inserting an NG tube for a client, which of the following assessment findings should the nurse expect to confirm correct tube placement?

• A. An x-ray shows the end of the tube above the pylorus.
• B. The tube is aspirated and contains clear gastric fluid.
• C. The tube is flushed with sterile water without resistance.
• D. The client does not cough or choke during tube insertion.

Correct answer: B

Rationale: Correct placement of an NG tube is confirmed by aspirating gastric fluid, which indicates that the tube is in the stomach. An x-ray can help visualize tube placement, but it alone does not confirm correct placement. Flushing the tube with sterile water without resistance indicates patency but not necessarily correct placement. The absence of coughing or choking does not confirm tube placement and is more related to the client's comfort during the procedure.

3. A client reports increased pain following physical therapy. Which of the following questions should be asked to assess the quality of the pain?

• A. Is your pain sharp or dull?
• B. Is your pain constant or intermittent?
• C. On a scale from 1 to 10, how severe is your pain?
• D. Where exactly is your pain located?

Correct answer: A

Rationale: Correct Answer: A. Asking whether the pain is sharp or dull helps in determining the quality of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate chronic issues. Choices B, C, and D focus on different aspects of pain assessment. Option B pertains to the pattern of pain, either constant or intermittent. Option C addresses the severity of pain on a numerical scale. Option D inquires about the location of pain. While all these questions are essential in pain assessment, when specifically evaluating the quality of pain, distinguishing between sharp and dull sensations is crucial.

4. After a renal biopsy, a client has returned to the unit. Which of the following nursing interventions is appropriate?

• A. Ambulate the client 4 hours after the procedure
• B. Maintain the client on NPO status for 24 hours
• C. Monitor vital signs
• D. Change the dressing every 8 hours

Correct answer: C

Rationale: Monitoring vital signs is crucial after a renal biopsy to promptly detect any signs of bleeding or complications. Ambulating the client 4 hours after the procedure may increase the risk of bleeding, so it is not appropriate. Maintaining the client on NPO status for 24 hours is not necessary unless specifically ordered by the healthcare provider. Changing the dressing every 8 hours is not typically indicated unless there is a specific concern or order to do so.

5. The healthcare provider is reviewing the plan of care for a client with a newly placed colostomy. Which outcome would indicate effective client teaching?

• A. Client demonstrates how to irrigate the colostomy.
• B. Client verbalizes understanding of dietary changes.
• C. Client performs ostomy care independently.
• D. Client expresses feelings about the impact of the colostomy.

Correct answer: C

Rationale: The correct answer is C because effective teaching is demonstrated when the client can independently perform ostomy care. This indicates that the client has understood and retained the information provided during teaching. Choices A, B, and D are incorrect because demonstrating how to irrigate the colostomy, verbalizing understanding of dietary changes, and expressing feelings about the impact of the colostomy are important aspects of care but do not directly reflect the client's ability to apply the taught information in a practical setting.

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