Nursing Elites

1. After administering a proton pump inhibitor, which action should the nurse take to evaluate the effectiveness of the medication?

• A. Monitor gastrointestinal pain
• B. Ask the client about pain levels
• C. Check the client's vital signs
• D. Assess for signs of bleeding

Correct answer: B

Rationale: The correct answer is to ask the client about pain levels. Proton pump inhibitors (PPIs) work by reducing stomach acid to alleviate gastrointestinal pain. By inquiring about the client's pain experience, the nurse can directly assess the effectiveness of the medication. Monitoring bowel movements (Choice A) is not directly related to evaluating the effectiveness of a PPI. Checking vital signs (Choice C) may not reflect the medication's effectiveness in reducing stomach acid. Assessing for signs of bleeding (Choice D) is important but not the most direct way to evaluate the effectiveness of a PPI.

2. A client receiving total parenteral nutrition (TPN) reports nausea and dizziness. What action should the nurse take first?

• A. Check the client's blood glucose level.
• B. Check the client's vital signs and blood pressure.
• C. Decrease the infusion rate of TPN.
• D. Administer antiemetic medication as prescribed.

Correct answer: B

Rationale: When a client receiving total parenteral nutrition (TPN) reports symptoms like nausea and dizziness, the first action the nurse should take is to check the client's vital signs and blood pressure. This assessment helps determine the client's overall stability and can provide crucial information to guide further interventions. Checking the blood glucose level (Choice A) may be relevant but is not the priority in this situation. Decreasing the infusion rate of TPN (Choice C) may be necessary but should be based on assessment findings. Administering antiemetic medication (Choice D) should not be the initial action without first assessing the client's vital signs.

3. A 4-year-old child falls off a tricycle and is admitted for observation. How can the nurse best facilitate the child's cooperation during the assessment?

• A. Ask the parent to hold the child during the assessment.
• B. Allow the child to play with a syringe without a needle.
• C. Ask the child to blow out the penlight as if to simulate success.
• D. Explain the function of each organ during the assessment.

Correct answer: C

Rationale: Engaging the child in blowing out the penlight simulates play and can reduce fear, helping with cooperation during the assessment. Choice A is not recommended as it may increase anxiety by separating the child from the parent. Choice B is not appropriate as it involves playing with a syringe, which may not be safe or suitable. Choice D is not ideal for a 4-year-old child as understanding organ functions may be beyond their developmental level.

4. A client with asthma is experiencing wheezing. What is the nurse’s priority intervention?

• A. Administer a bronchodilator immediately.
• B. Increase the client's oxygen flow rate.
• C. Perform a chest x-ray to assess lung function.
• D. Place the client in a high Fowler’s position.

Correct answer: A

Rationale: The correct answer is A: Administer a bronchodilator immediately. Wheezing in a client with asthma indicates bronchoconstriction, which can compromise airflow. Administering a bronchodilator is the priority intervention as it helps to open the airways, relieve bronchoconstriction, and improve breathing. Increasing the oxygen flow rate (choice B) may be necessary but is not the priority when the airways are constricted. Performing a chest x-ray (choice C) is not the immediate action needed in this situation. Placing the client in a high Fowler's position (choice D) may provide some relief, but administering a bronchodilator to address the bronchoconstriction is the priority intervention.

5. A client with schizophrenia is experiencing auditory hallucinations. What is the nurse's best response?

• A. Encourage the client to ignore the voices and stay focused on reality.
• B. Acknowledge the client's feelings and ask what the voices are saying.
• C. Redirect the conversation to help distract the client from the hallucinations.
• D. Offer reassurance that the voices cannot harm the client.

Correct answer: B

Rationale: The best response for a client with schizophrenia experiencing auditory hallucinations is to acknowledge the client's feelings and ask what the voices are saying. This approach helps build rapport with the client, demonstrates empathy, and allows the nurse to assess the content of the hallucinations. Understanding the content is crucial to determine whether the client is at risk of harm. Encouraging the client to ignore the voices (Choice A) may invalidate their experience. Redirecting the conversation (Choice C) may not address the underlying issue of the hallucinations. Offering reassurance (Choice D) without understanding the content may overlook potential risks.

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