Nursing Elites

1. A client reports abdominal pain. An assessment by the nurse reveals a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft tender abdomen, and menses overdue by 2 days. Which of the following findings should be the nurse's priority?

• A. Temperature
• B. Heart rate
• C. Abdominal tenderness
• D. Overdue menses

Correct answer: A

Rationale: The nurse's priority should be the client's temperature. A high temperature of 39.2 degrees C (102 degrees F) indicates a potential infection or inflammation that requires immediate attention. While heart rate and abdominal tenderness are important assessments, the temperature takes precedence as it signals a more urgent issue. Overdue menses, although significant, are not the priority in this scenario when compared to the possibility of an acute infection or inflammatory process.

2. When explaining the procedure for collecting a 24-hour urine specimen for creatinine clearance to an older adult male, what should the nurse do next?

• A. Assess the client for confusion and reteach the procedure
• B. Check the urine for color and texture
• C. Empty the urinal contents into the 24-hour collection container
• D. Discard the contents of the urinal

Correct answer: A

Rationale: The correct next step for the nurse is to assess the client for confusion and reteach the procedure. This is crucial to ensure that the older adult male understands the process correctly, reducing the likelihood of errors in collecting the 24-hour urine specimen for creatinine clearance. Checking the urine for color and texture (Choice B) is not the immediate next step as the focus should be on patient understanding first. Emptying the urinal contents into the 24-hour collection container (Choice C) assumes prior knowledge on the client's part and skips the critical step of ensuring comprehension. Discarding the contents of the urinal (Choice D) is incorrect and wasteful since the urine is necessary for the 24-hour collection process.

3. A client is scheduled for an intravenous pyelogram. Which of the following actions is appropriate for the nurse to include?

• A. Monitor the client for pain in the suprapubic region.
• B. Ensure the client is free of metal objects.
• C. Administer 240 mL (8 oz) of oral contrast before the procedure.
• D. Assist the client with a bowel cleansing.

Correct answer: B

Rationale: The correct action for the nurse to include before an intravenous pyelogram is ensuring the client is free of metal objects. Metal objects can interfere with the imaging procedure and may need to be removed to prevent artifacts. Monitoring for pain in the suprapubic region (choice A) is not directly related to the procedure and is not a standard pre-procedure action. Administering oral contrast (choice C) is more common for other imaging studies like a CT scan, not an intravenous pyelogram. Assisting with a bowel cleansing (choice D) is not typically required before an intravenous pyelogram.

4. A nurse at a clinic is collecting data about pain from a client who reports severe abdominal pain. The nurse asks the client if there have been any accompanying nausea and vomiting. Which of the following pain characteristics is the nurse attempting to determine?

• A. Presence of associated manifestations.
• B. Location of the pain
• C. Pain quality
• D. Aggravating and relieving factors

Correct answer: A

Rationale: The nurse is identifying associated manifestations like nausea and vomiting that may occur with the pain. The presence of associated manifestations helps in understanding the broader clinical picture and potential causes of the pain. Location refers to where the pain is felt, pain quality describes the nature of the pain, and aggravating and relieving factors relate to what makes the pain worse or better. In this scenario, the focus is on identifying additional symptoms that can provide important diagnostic clues.

5. A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue measuring the client's vital signs every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

• A. Document the provider's directive in the medical record
• B. Notify the nursing manager
• C. Consult the facility's risk manager
• D. Complete an incident report

Correct answer: B

Rationale: In this scenario, the nurse is facing a critical situation with a client showing signs of hemorrhagic shock. The surgeon's directive of waiting for an hour without providing immediate intervention poses a risk to the client's well-being. The nurse should prioritize the client's safety and advocate for timely and appropriate care. Notifying the nursing manager is the correct action as it activates the chain of command to ensure that the client receives the necessary care promptly. Documenting the provider's directive, consulting the risk manager, or completing an incident report are not the immediate actions needed to address the client's deteriorating condition and ensure patient safety.

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