Nursing Elites

1. A nurse is talking with an adolescent who is having difficulty dealing with several issues. Which of the following issues should the nurse identify as the priority?

• A. “I kind of like this boy in my class, but he doesn’t like me back.”
• B. “I want to hang out with the kids in the science club, but the jocks pick on them.”
• C. “I am so fat, I skip meals to try to lose weight.”
• D. “My dad wants me to be a lawyer like him, but I just want to dance.”

Correct answer: C

Rationale: The correct answer is C. Skipping meals to lose weight may indicate an eating disorder or significant distress, which can have serious health implications. This behavior raises concerns about the adolescent's physical and mental well-being. The nurse should prioritize addressing potential eating disorders and body image issues in this situation. Choices A, B, and D, while important, do not pose an immediate risk to the adolescent's health or well-being compared to the potential consequences of disordered eating behavior.

2. A client with a history of chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute via nasal cannula. The client is short of breath and has a pulse oximetry reading of 88%. What action should the LPN take first?

• A. Increase the oxygen flow rate to 4 liters per minute.
• B. Reposition the client to a high Fowler's position.
• C. Notify the healthcare provider of the client's condition.
• D. Encourage the client to use pursed-lip breathing.

Correct answer: B

Rationale: Repositioning the client to a high Fowler's position should be the first action taken by the LPN. This position helps improve oxygenation by maximizing lung expansion, making it easier for the client to breathe. Increasing the oxygen flow rate without addressing positioning may not fully optimize oxygen delivery. Notifying the healthcare provider should come after immediate interventions. Encouraging pursed-lip breathing is beneficial but should follow the initial positioning to further assist the client in managing their breathing difficulty.

3. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

4. A nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?

• A. Administer the medication with the needle at a 45-degree angle.
• B. Administer the medication with the needle at a 90-degree angle.
• C. Administer the medication with the needle at a 30-degree angle.
• D. Administer the medication with the needle at a 15-degree angle.

Correct answer: B

Rationale: Enoxaparin should be administered with the needle at a 90-degree angle to ensure proper subcutaneous delivery. Choice B is correct as it aligns with the recommended angle for subcutaneous injections. Administering enoxaparin at a 45-degree angle (Choice A), 30-degree angle (Choice C), or 15-degree angle (Choice D) would not be appropriate and may lead to improper administration or absorption of the medication.

5. A nurse is caring for a client postoperatively. When the nurse prepares to change the dressing, the client says it hurts. Which intervention is the nurse’s priority action?

• A. Administer pain medication 45 minutes prior to dressing change.
• B. Change the dressing quickly to minimize pain.
• C. Provide reassurance to the client that the pain will pass.
• D. Use a less painful dressing technique.

Correct answer: A

Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.

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