Nursing Elites

1. How should pain be assessed in a non-verbal patient?

• A. Observe facial expressions
• B. Use the Wong-Baker faces scale
• C. Assess heart rate
• D. Ask the patient to rate their pain

Correct answer: A

Rationale: Observing facial expressions is essential in assessing pain levels in non-verbal patients. Non-verbal cues, such as facial grimacing, furrowed brows, or clenched jaws, can provide valuable information about the patient's pain experience. Using the Wong-Baker faces scale or assessing heart rate may not be as effective in non-verbal patients as they are unable to communicate their pain through these methods. Asking the patient to rate their pain is also not suitable for non-verbal patients as they may not have the ability to verbally communicate their pain levels.

2. A nurse is assessing a client who has left-sided heart failure. Which of the following should the nurse identify as a manifestation of pulmonary congestion?

• A. Frothy, pink sputum
• B. Jugular vein distention
• C. Weight gain
• D. Bradypnea

Correct answer: A

Rationale: Correct! Frothy, pink sputum is a classic sign of pulmonary congestion in left-sided heart failure. This occurs due to the accumulation of fluid in the lungs, leading to the coughing up of frothy, pink-tinged sputum. Jugular vein distention (choice B) is more indicative of right-sided heart failure, where fluid backs up into the systemic circulation. Weight gain (choice C) may occur due to fluid retention, but it is not a direct manifestation of pulmonary congestion. Bradypnea (choice D) refers to abnormally slow breathing and is not specifically associated with pulmonary congestion.

3. A client with osteoporosis is being taught about dietary management. Which of the following foods should be recommended?

• A. Almonds
• B. Spinach
• C. Yogurt
• D. Carrots

Correct answer: C

Rationale: Yogurt is a calcium-rich food that helps strengthen bones and should be recommended to clients with osteoporosis. Almonds, spinach, and carrots do not provide as much calcium as yogurt and are not as beneficial for individuals with osteoporosis.

4. A nurse is caring for a client who is at 38 weeks of gestation and has preeclampsia. Which of the following findings should the nurse report to the provider?

• A. Fetal heart rate of 110/min
• B. 1+ pitting edema
• C. Blood pressure 138/80 mm Hg
• D. Urine output of 20 mL/hr

Correct answer: D

Rationale: The correct answer is D. Urine output less than 30 mL/hr indicates decreased kidney perfusion, which is a serious complication of preeclampsia. Reporting this finding is crucial for prompt intervention. Choices A, B, and C are not the priority as fetal heart rate of 110/min, 1+ pitting edema, and blood pressure of 138/80 mm Hg are within normal limits for a client with preeclampsia at 38 weeks of gestation.

5. A client is being discharged with a new prescription for levothyroxine. Which of the following instructions should the nurse include?

• A. Take this medication with meals to avoid stomach upset.
• B. Take this medication at the same time every day.
• C. Notify your provider if you experience chest pain or palpitations.
• D. Take this medication with antacids to reduce indigestion.

Correct answer: B

Rationale: The correct answer is B: 'Take this medication at the same time every day.' It is crucial to take levothyroxine at the same time each day to maintain consistent thyroid hormone levels. Choice A is incorrect because levothyroxine should be taken on an empty stomach, usually in the morning. Choice C is important but not specific to the administration of levothyroxine. Choice D is incorrect as antacids can interfere with the absorption of levothyroxine.

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