Nursing Elites

1. How should a healthcare professional assess a patient's pain who is non-verbal?

• A. Looking for changes in vital signs that may indicate pain
• B. Using alternative methods like touch or distraction
• C. Using a pain scale appropriate for non-verbal patients
• D. Observing for facial expressions or other non-verbal cues

Correct answer: A

Rationale: When assessing pain in non-verbal patients, looking for changes in vital signs that may indicate pain is crucial. While using alternative methods like touch or distraction can be helpful, they may not directly indicate the presence of pain. Using a pain scale appropriate for non-verbal patients is important, but it may not always provide immediate feedback. Observing for facial expressions or other non-verbal cues can be subjective and may not always accurately reflect the level of pain the patient is experiencing. Therefore, monitoring vital signs is a more objective way to assess pain in non-verbal patients.

2. A nurse is caring for a client who is in labor and has an external fetal monitor in place. The nurse observes late decelerations in the fetal heart rate. Which of the following actions should the nurse take first?

• A. Decrease the client's IV fluids
• B. Reposition the client
• C. Administer oxygen by face mask
• D. Document the findings

Correct answer: C

Rationale: Administering oxygen by face mask is the priority intervention when late decelerations are observed in the fetal heart rate. Late decelerations indicate uteroplacental insufficiency, and administering oxygen helps to improve fetal oxygenation. Repositioning the client may also be necessary to relieve pressure on the umbilical cord, but providing oxygen takes precedence to enhance fetal oxygenation. Decreasing IV fluids may not directly address the underlying issue leading to late decelerations. Documenting the findings is important but should not be the first action taken when managing late decelerations.

3. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?

• A. Encourage visitors during visiting hours.
• B. Keep the patient on fall precautions until discharge.
• C. Check on the patient every shift.
• D. Raise all four side rails.

Correct answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

4. A client with a DNR order has requested resuscitation during a visit from the family. What is the nurse's best course of action?

• A. Follow the family's request and perform CPR.
• B. Explain to the family that the DNR must be honored.
• C. Call the healthcare provider to cancel the DNR order.
• D. Delay resuscitation until further clarification can be made.

Correct answer: B

Rationale: The correct course of action for the nurse is to explain to the family that the DNR (Do Not Resuscitate) order must be honored. It is essential for the nurse to uphold the client's wishes as documented in the DNR order. Performing CPR against the client's expressed wishes in the DNR order would violate ethical and legal standards. Calling the healthcare provider to cancel the DNR order without the client's consent is inappropriate and goes against the client's autonomy. Delaying resuscitation can be detrimental in an emergency situation and may not align with the client's wishes as outlined in the DNR order.

5. A healthcare provider is reviewing a client's lab results. Which of the following lab values should the provider report?

• A. Magnesium 1.9 mEq/L
• B. Potassium 3.6 mEq/L
• C. Sodium 126 mEq/L
• D. Chloride 99 mEq/L

Correct answer: C

Rationale: The correct answer is C: Sodium 126 mEq/L. A sodium level of 126 mEq/L is below the normal range, indicating hyponatremia, which can have serious health implications and should be reported to the healthcare provider for further evaluation and intervention. Choices A, B, and D are within or close to the normal ranges for magnesium, potassium, and chloride, respectively, and do not require immediate reporting as they are not significantly abnormal.

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