Nursing Elites

1. The father of an 11-year-old client reports to the nurse that the client has been 'wetting the bed' since the passing of his mother and is concerned. Which action is most important for the nurse to take?

• A. Reassure the father that it is normal for a child to wet the bed after a traumatic event
• B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed
• C. Inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma
• D. Refer the father and the client to a psychologist

Correct answer: C

Rationale: Bedwetting after trauma, such as losing a parent, is common in children. The nurse should inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma. Reassurance and understanding are essential in addressing the child's emotional needs during this difficult time. Choice A is incorrect as it focuses on puberty rather than trauma as the underlying cause. Choice B is incorrect as it provides inaccurate information about nocturnal emissions and developmental delay. Choice D is premature as the first step should be to provide education and support before considering a referral to a psychologist.

2. The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

• A. 0.8 mL
• B. 0.75 mL
• C. 0.7 mL
• D. 0.9 mL

Correct answer: A

Rationale: To calculate the mL to administer, divide the ordered dose (3 mg) by the concentration (4 mg/mL). 3 mg ÷ 4 mg/mL = 0.75 mL. Rounding to the nearest tenth, the correct dose to administer is 0.8 mL.

3. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?

• A. Assess the client for confusion and reteach the procedure
• B. Check the urine for color and texture
• C. Empty the urinal contents into the 24-hour collection container
• D. Discard the contents of the urinal

Correct answer: C

Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.

4. The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?

• A. Apply a warm compress proximal to the site.
• B. Check for kinks in the tubing and raise the IV pole.
• C. Adjust the tape that stabilizes the needle.
• D. Flush with normal saline and recount the drop rate.

Correct answer: B

Rationale: In this scenario, the appropriate next step for the healthcare provider is to check for kinks in the tubing and raise the IV pole. These issues can commonly cause a slowed IV rate. Applying a warm compress (Choice A) may not address the underlying problem of kinked tubing or incorrect IV pole height. Adjusting the tape that stabilizes the needle (Choice C) is important for securement but is not the priority in this situation. Flushing with normal saline and recounting the drop rate (Choice D) should only be done after ruling out mechanical issues like kinks in the tubing.

5. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

• A. The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record
• B. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace
• C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
• D. Completing the electronic record during an interview is a legal obligation of the examining nurse

Correct answer: C

Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.

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