Nursing Elites

1. A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

• A. Self-report of pain
• B. Nonverbal behavior
• C. Severity of the condition
• D. Vital signs

Correct answer: A

Rationale: The correct answer is A: Self-report of pain. Pain is a subjective experience, and the most reliable way to assess it is through the client's self-report. While nonverbal behaviors and vital signs can provide additional information, they are not as reliable as the client's own report of pain. The severity of the condition may influence the experience of pain but is not a direct indicator of the client's pain level.

2. A nurse is monitoring an older adult female client who had a myocardial infarction (MI) for the development of an acute kidney injury (AKI). Which of the following findings should the nurse identify as indicating an increased risk of AKI?

• A. Magnesium 2.0 mEq/L
• B. Blood urea nitrogen (BUN) 20 mg/dL
• C. Serum Osmolality 290 mOsm/kg H2O
• D. Serum creatinine 1.8 mg/dL

Correct answer: D

Rationale: An elevated serum creatinine level (1.8 mg/dL) is a significant indicator of potential kidney impairment. In acute kidney injury (AKI), serum creatinine levels rise due to decreased kidney function, reflecting the kidneys' inability to effectively filter waste from the blood. Magnesium level, BUN, and serum osmolality are not direct indicators of kidney function or risk of AKI. Magnesium levels are more related to electrolyte balance, BUN can be affected by factors other than kidney function, and serum osmolality reflects the concentration of solutes in the blood, not specifically kidney function.

3. A nurse manager is implementing a quality improvement project to reduce the number of methicillin-resistant Staphylococcus aureus (MRSA) infections at the facility. Which of the following actions should the nurse manager take first?

• A. Develop an MRSA protocol for implementation.
• B. Provide educational in-services for staff.
• C. Evaluate outcomes resulting from interventions.
• D. Conduct a chart review to evaluate precipitating factors of clients who develop MRSA.

Correct answer: D

Rationale: Conducting a chart review to evaluate the precipitating factors of clients who develop MRSA is the initial step in reducing these infections. By identifying factors contributing to MRSA infections, the nurse manager can develop targeted interventions. Developing an MRSA protocol (choice A) and providing educational in-services (choice B) would be premature without understanding the specific factors at play. Evaluating outcomes (choice C) should come after implementing interventions based on the findings from the chart review.

4. A nurse is providing discharge teaching to a client following a cataract extraction. Which of the following instructions should the nurse include?

• A. Bend at the waist when picking up objects.
• B. Avoid lying on the operative side.
• C. Avoid lifting more than 10 lb.
• D. Apply ice to the affected eye.

Correct answer: C

Rationale: The correct answer is C: 'Avoid lifting more than 10 lb.' After a cataract extraction, the nurse should instruct the client to avoid lifting heavy objects to prevent increased intraocular pressure, which could lead to complications. Choices A, B, and D are incorrect. A - 'Bend at the waist when picking up objects' can increase intraocular pressure; B - 'Avoid lying on the operative side' is not a specific concern related to cataract extraction; D - 'Apply ice to the affected eye' is not a standard post-cataract extraction instruction.

5. A nurse is planning preoperative care for a client who will undergo surgery. Which of the following is the priority action by the nurse?

• A. Discuss whether family members will assist with postoperative care
• B. Review the client's current home environment
• C. Identify the client's usual coping mechanisms
• D. Determine what the client knows about the surgery

Correct answer: D

Rationale: In the preoperative phase, determining what the client knows about the surgery is the priority. This action helps address misconceptions, provide necessary information, and ensure the client's understanding and cooperation. Choices A, B, and C are important aspects of preoperative care but assessing the client's knowledge about the surgery takes precedence to alleviate fears, enhance communication, and optimize outcomes.

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