Nursing Elites

1. The nurse is assessing a client who reports sudden onset of severe eye pain and blurred vision. What is the priority nursing intervention?

• A. Administer prescribed pain medication.
• B. Notify the healthcare provider immediately.
• C. Place an eye patch over the affected eye.
• D. Prepare the client for a CT scan.

Correct answer: B

Rationale: The correct answer is to notify the healthcare provider immediately (Choice B). Sudden severe eye pain and blurred vision can indicate acute angle-closure glaucoma, which is a medical emergency requiring prompt evaluation and treatment to prevent vision loss. Administering pain medication (Choice A) may provide temporary relief but does not address the underlying cause. Placing an eye patch (Choice C) may not be appropriate without knowing the exact cause of the symptoms. Preparing for a CT scan (Choice D) is not the immediate priority in this situation where urgent medical attention is needed.

2. The parents of a child who has been diagnosed with sickle cell anemia ask why their child experiences pain. What is the most likely cause of the pain?

• A. Inflammation of the vessels
• B. Obstructed blood flow
• C. Overhydration
• D. Stress-related headaches

Correct answer: B

Rationale: The correct answer is B: Obstructed blood flow. In sickle cell anemia, the sickle-shaped red blood cells can clump together, obstructing blood flow in the vessels. This obstruction leads to tissue hypoxia (lack of oxygen) and necrosis, causing pain. Choice A, inflammation of the vessels, is not the primary cause of pain in sickle cell anemia. Choice C, overhydration, is unrelated to the pathophysiology of sickle cell anemia. Choice D, stress-related headaches, is not a characteristic symptom of sickle cell anemia.

3. A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the post-anesthesia unit. Before selecting which medication to administer, which action should the nurse implement?

• A. Document the client's report of pain in the electronic medical record.
• B. Determine which prescription will have the quickest onset of action.
• C. Compare the client's pain scale rating with the prescribed dosing.
• D. Ask the client to choose which medication is needed for the pain.

Correct answer: C

Rationale: The correct action the nurse should implement before selecting which medication to administer to a postoperative client who reports incisional pain is to compare the client's pain scale rating with the prescribed dosing. This ensures that the client receives the appropriate medication based on their pain level. Documenting the client's report of pain in the electronic medical record (Choice A) is important but should come after ensuring the right medication is given. Determining which prescription will have the quickest onset of action (Choice B) may not be the most relevant factor to consider when choosing the appropriate medication. Asking the client to choose the medication needed for the pain (Choice D) may not be appropriate as the nurse should rely on the pain scale rating and prescribed dosing to make a clinical decision.

4. A young female client with 7 children is having frequent morning headaches, dizziness, and blurred vision. Her BP is 168/104. The client reports that her husband recently lost his job and she is not sleeping well. After administering a STAT dose of an antihypertensive IV med, which intervention is most important for the nurse to implement?

• A. Measure urine output hourly to assess for renal perfusion
• B. Request a prescription for pain medication
• C. Use an automated BP machine to monitor for hypotension
• D. Provide a quiet environment with low lighting

Correct answer: C

Rationale: Using an automated BP machine is crucial to continuously monitor for hypotension after administering an antihypertensive medication. This is essential to prevent a rapid drop in blood pressure that could lead to complications. Measuring urine output hourly to assess for renal perfusion is important but not the most immediate concern in this situation. Requesting pain medication is not relevant to the primary issue of managing blood pressure. Providing a quiet environment with low lighting may be beneficial for the client's overall well-being but is not as critical as monitoring for potential hypotension.

5. A client who experienced partial-thickness burns with over 50% body surface area (BSA) 2 weeks ago suddenly becomes restless and agitated.

• A. Increase the room temperature.
• B. Assess the oxygen saturation.
• C. Continue to monitor vital signs.
• D. Notify the rapid response team.

Correct answer: D

Rationale: In a burn patient with sudden restlessness and agitation, it is crucial to consider hypoxia or other critical conditions. As such, notifying the rapid response team is the most appropriate action to ensure prompt assessment and intervention. Increasing room temperature (Choice A) is not the priority in this scenario. While monitoring vital signs (Choice C) is important, the sudden change in behavior warrants immediate action. Assessing oxygen saturation (Choice B) is a step in the right direction, but involving the rapid response team ensures a comprehensive evaluation and timely management of the patient's condition.

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