Nursing Elites

1. A client is being taught how to use a PCA pump postoperatively. Which statement indicates understanding?

• A. I should wait until the pain is severe before using the PCA pump.
• B. My family can press the button for me when I'm asleep.
• C. I will press the button when I start to feel pain.
• D. I will only press the button once per hour.

Correct answer: C

Rationale: The correct answer is C because the client should press the PCA pump button when they start to feel pain. This approach helps maintain pain control effectively. Choice A is incorrect because waiting for the pain to become severe before using the PCA pump can lead to inadequate pain management. Choice B is incorrect because only the client should operate the PCA pump to ensure the correct dosage is administered. Choice D is incorrect because the client should press the button as needed when experiencing pain, rather than limiting its use to once per hour.

2. A client is found on the floor of their room experiencing a seizure. Which of the following actions is the priority for the nurse?

• A. Place the client on their side with their head forward
• B. Call for help
• C. Protect the client's head
• D. Restrain the client

Correct answer: A

Rationale: During a seizure, the priority action for the nurse is to place the client on their side with their head forward. This position helps maintain an open airway and prevents aspiration, which is crucial in managing the client's safety during a seizure. Calling for help is important but ensuring the client's immediate safety by positioning them correctly takes precedence. Protecting the client's head can be done concurrently while positioning the client. Restraint is not appropriate during a seizure as it can lead to injuries and complications.

3. A healthcare provider is assessing a newborn who is 48 hours old and is experiencing opioid withdrawals. Which of the following findings should the healthcare provider expect?

• A. Hypotonia
• B. Moderate tremors of the extremities
• C. Axillary temperature 36.1°C (96.9°F)
• D. Excessive crying

Correct answer: B

Rationale: The correct answer is B: Moderate tremors of the extremities. In newborns experiencing opioid withdrawals, moderate tremors of the extremities are a common sign. Other signs of opioid withdrawal in newborns may include irritability, feeding difficulties, and gastrointestinal disturbances. Choice A, hypotonia, is not typically associated with opioid withdrawal in newborns. Choice C, an axillary temperature of 36.1°C (96.9°F), falls within the normal range for newborns and is not specifically indicative of opioid withdrawal. Choice D, excessive crying, is not a typical sign of opioid withdrawal in newborns.

4. A client is prescribed insulin glargine. Which of the following should the nurse instruct the client to do regarding administration of this medication?

• A. Inject insulin glargine 30 minutes before a meal.
• B. Shake the insulin vial before administration.
• C. Administer insulin glargine once daily at bedtime.
• D. Take insulin glargine with short-acting insulin.

Correct answer: C

Rationale: The correct answer is C: Administer insulin glargine once daily at bedtime. Insulin glargine is a long-acting insulin that provides a basal level of insulin throughout the day. It should be given at the same time each day, usually at bedtime, to maintain a consistent blood sugar level. Choices A, B, and D are incorrect. Injecting insulin glargine before a meal (Choice A) is not necessary as it is a long-acting insulin. Shaking the insulin vial (Choice B) is not recommended as it may cause bubbles to form, affecting the accuracy of the dose. Taking insulin glargine with short-acting insulin (Choice D) is not a typical practice as insulin glargine is used for basal insulin coverage.

5. A nurse is assessing a client with osteoporosis who is experiencing severe pain. The client's respiratory rate is 14/min. Which of the following medications should the nurse administer first?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: The correct answer is B, Hydromorphone. Hydromorphone is an opioid analgesic commonly used to manage severe pain effectively. In this case, the client's stable respiratory rate of 14/min indicates that it is safe to administer an opioid for pain relief. Promethazine (choice A) is an antiemetic and antihistamine, not the first choice for severe pain management. Ketorolac (choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that may not be potent enough for severe pain relief associated with osteoporosis. Amitriptyline (choice D) is a tricyclic antidepressant, not typically used as a first-line medication for severe pain.

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