Nursing Elites

1. The nurse is assessing the client recently returned from surgery. The nurse is aware that the best way to assess pain is to:

• A. Take the blood pressure, pulse, and temperature
• B. Ask the client to rate his pain on a scale of 0-5
• C. Watch the client's facial expression
• D. Ask the client if he is in pain

Correct answer: B

Rationale: The best way to evaluate pain levels is to ask the client to rate his pain on a scale. This method provides a more standardized and quantifiable measure of pain compared to subjective observations like facial expressions (choice C) or direct questioning (choice D). Monitoring vital signs (choice A) can be part of pain assessment but is not as specific or reliable as asking the client to self-report pain intensity.

2. Spirituality affects a client's life in all of the following areas except:

• A. nutritional intake.
• B. ability to handle stress.
• C. sexual expression.
• D. genetic makeup.

Correct answer: D

Rationale: Spirituality is a belief in or relationship with some higher power, creative force, divine being, or infinite source of energy. It can influence areas such as nutritional intake, the ability to handle stress, and sexual expression by providing comfort, guidance, and a sense of purpose. However, spirituality does not have any effect on genetic makeup, as genetics are determined by biological inheritance and not influenced by spiritual beliefs. Choices A, B, and C are directly influenced by an individual's spiritual beliefs and practices, impacting their overall well-being and behavior.

3. The client is receiving heparin for thrombophlebitis of the left lower extremity. Which of the following drugs reverses the effects of heparin?

• A. Cyanocobalamin
• B. Protamine sulfate
• C. Streptokinase
• D. Sodium warfarin

Correct answer: B

Rationale: The correct answer is Protamine sulfate. Protamine sulfate is the antidote for heparin, as it reverses its effects. Cyanocobalamin is a form of Vitamin B12 and is not used to reverse heparin effects. Streptokinase is a thrombolytic agent that is used to dissolve blood clots, not to reverse heparin effects. Sodium warfarin is an anticoagulant, but it is not the antidote for heparin. Therefore, answers A, C, and D are incorrect as they do not reverse the effects of heparin.

4. An adult who had been abused as a child is discussing the group therapy program. Which statement indicates that the client has gained insight?

• A. "I think I was a lonely child because I could not tell anyone about my abuse."?
• B. "I am now aware of how deep-seated my anger is. Before, I did not realize I was angry."?
• C. "The program has given me the courage to tell my mother how I felt about her role in my hurt."?
• D. "There are so many people just like me, who are just normal people that had bad things happen to them."?

Correct answer: B

Rationale: The correct answer demonstrates insight gained by the client regarding their emotional state. Recognizing deep-seated anger that was previously unrecognized indicates progress in understanding their emotions and the impact of past abuse. Choice A reflects a sense of loneliness due to an inability to share about the abuse, which does not directly address emotional insight. Choice C shows progress in addressing relationships but does not specifically relate to emotional awareness. Choice D acknowledges shared experiences but does not reflect personal emotional growth or insight.

5. A client arrives in the emergency room with a possible fractured femur. The nurse should anticipate an order for:

• A. Trendelenburg position
• B. Ice to the entire extremity
• C. Buck's traction
• D. An abduction pillow

Correct answer: C

Rationale: The correct answer is Buck's traction. This intervention is used to realign the fractured femur, reduce spasms, and alleviate pain. Placing the client in the Trendelenburg position is inappropriate for a femur fracture, making answer A incorrect. While ice may be used post-repair, applying it to the entire extremity is unnecessary, so answer B is wrong. An abduction pillow is typically employed following a total hip replacement, not for a fractured femur, rendering answer D incorrect.

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