Nursing Elites

1. The nurse is assessing a client with a diagnosis of pheochromocytoma. Which symptom should the nurse expect to find?

• A. Hypertension
• B. Bradycardia
• C. Hypoglycemia
• D. Weight gain

Correct answer: A

Rationale: The correct answer is A: Hypertension. Pheochromocytoma is characterized by the overproduction of catecholamines, leading to symptoms such as hypertension. Bradycardia (Choice B) is not typical in pheochromocytoma as increased catecholamines usually lead to tachycardia. Hypoglycemia (Choice C) and weight gain (Choice D) are not commonly associated symptoms of pheochromocytoma.

2. A nurse is observing a newly licensed nurse providing care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was administered 6 hours ago. The prescription specifies administration every 4 hours PRN for pain. The nurse administered the medication and followed up with the client 40 minutes later, who reported improvement. What did the newly licensed nurse overlook in the nursing process?

• A. Assessment
• B. Planning
• C. Intervention
• D. Evaluation

Correct answer: A

Rationale: The correct answer is 'Assessment.' In the nursing process, assessment is the first step, crucial before any intervention. Assessment involves gathering data about the client's condition to establish a baseline for evaluating responses to interventions. In this scenario, the newly licensed nurse missed assessing the client's pain intensity, location, quality, and other relevant factors before administering the pain medication. While the follow-up evaluation with the client is commendable, it cannot replace the initial assessment. Planning involves setting goals and outcomes, intervention is the action taken to achieve these goals, and evaluation assesses the client's response to the intervention.

3. A nurse is preparing change of shift report after the night shift using one SBAR communication tool. Which of the following data should the nurse include when reporting background information?

• A. “Blood pressure 160/92 mm Hg”
• B. “Start the first dose of penicillin at 1200”
• C. “Pain rating of 5 on a scale from 0 to 10”
• D. “Code status: do-not-resuscitate”

Correct answer: B

Rationale: The correct answer is B. When providing background information in a shift report using the SBAR communication tool, the nurse should include details related to medication administration and orders. This helps ensure continuity of care and accurate handover of responsibilities. Choices A, C, and D do not typically fall under background information for shift reports. A blood pressure reading, pain rating, and code status are more relevant to the patient's current condition and status, rather than background information about medications or orders.

4. The debilitated patient is resisting attempts by the nurse to provide oral hygiene. Which action will the nurse take next?

• A. Insert an oral airway.
• B. Place the patient in a flat, supine position.
• C. Use undiluted hydrogen peroxide as a cleaner.
• D. Quickly proceed without talking to the patient.

Correct answer: A

Rationale: When a debilitated patient resists oral hygiene, the nurse should prioritize safety. Inserting an oral airway helps keep the mouth open, ensuring adequate access for oral care procedures while preventing any accidental biting or closure of the airway. Placing the patient in a flat, supine position may not address the resistance issue and can lead to aspiration risk. Using undiluted hydrogen peroxide is not recommended due to its potential harmful effects on oral tissues. Proceeding quickly without communication can escalate the situation and compromise patient-centered care.

5. A nurse is evaluating a client’s use of a cane. What is the correct use?

• A. Client holds the cane on the stronger side of the body.
• B. Client holds the cane on the weaker side of the body.
• C. Client holds the cane in front of the weaker side of the body.
• D. Client holds the cane in front of the stronger side of the body.

Correct answer: A

Rationale: The correct way to use a cane is for the client to hold it on the stronger side of the body. This positioning allows the cane to provide support to the weaker side, assisting with balance and stability. Placing the cane on the weaker side (Choice B) may not provide adequate support and could lead to an increased risk of falls. Holding the cane in front of the weaker side (Choice C) or in front of the stronger side (Choice D) does not optimize the support and stability needed while walking with a cane.

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