Nursing Elites

1. The patient is inquiring about the use of a PCA pump for pain management. Which statement by the patient indicates a need for additional education?

• A. "I will continue to report my pain score during assessments."?
• B. "I understand that there is a maximum dose per hour that I can receive regardless of how many times I press the button."?
• C. "I believe this new PCA pump will finally alleviate my back pain."?
• D. "I have more control over when and how much medication I receive."?

Correct answer: C

Rationale: The correct answer is, "I believe this new PCA pump will finally alleviate my back pain."? This statement indicates a need for additional education as it reflects an unrealistic expectation regarding pain management. It is essential for the patient to understand that while a PCA pump can provide effective pain relief, it may not completely eliminate pain. Option A is correct as it demonstrates the patient's understanding of the importance of reporting pain scores for proper pain management. Option B is correct as it shows the patient's awareness of the maximum dose limits to prevent overdose. Option D is correct as it highlights the patient's understanding of the control they have over their medication administration.

2. When performing an abdominal assessment, what is the correct order of the tasks?

• A. inspect, percuss, palpate, auscultate
• B. inspect, palpate, percuss, auscultate
• C. inspect, auscultate, percuss, palpate
• D. inspect, palpate, auscultate, percuss

Correct answer: C

Rationale: The correct order of tasks when performing an abdominal assessment is to first inspect the abdomen visually, then auscultate to assess bowel sounds without altering them, followed by percussing to assess the presence of tympany or dullness, and finally palpating to feel for any tenderness, masses, or organ enlargement. Placing palpation or percussion before auscultation, as in choices A, B, and D, can affect the bowel sounds and examination findings, making them incorrect sequences.

3. A 2-year-old child diagnosed with HIV comes to a clinic for immunizations. Which of the following vaccines should the nurse expect to administer in addition to the scheduled vaccines?

• A. pneumococcal vaccine
• B. hepatitis A vaccine
• C. Lyme disease vaccine
• D. typhoid vaccine

Correct answer: A

Rationale: For a 2-year-old child diagnosed with HIV, in addition to the scheduled vaccines, the nurse should expect to administer the pneumococcal vaccine. Children with HIV are at an increased risk of infections, including pneumococcal disease. The pneumococcal vaccine helps protect against serious pneumococcal infections like pneumonia, meningitis, and bacteremia. The hepatitis A vaccine is not specifically recommended for all children with HIV unless there are specific risk factors. The Lyme disease vaccine is for individuals at risk for Lyme disease, typically between the ages of 15 and 70, transmitted by ticks. The typhoid vaccine is usually recommended for individuals traveling to endemic areas or working in specific high-risk occupations like microbiology laboratories dealing with Salmonella typhi.

4. The client has an order for 0.45 mg of Diltiazem. The medication vial has a concentration of 3 mg/mL. How many mL of the drug should be administered?

• A. 0.15 mL
• B. 6.6 mL
• C. 1.5 mL
• D. 0.65 Ml

Correct answer: A

Rationale: To calculate the amount of drug to be administered, divide the ordered dose by the concentration of the medication in the vial. In this case, 0.45 mg � 3 mg/mL = 0.15 mL. Therefore, the correct answer is 0.15 mL. Choice B (6.6 mL) is incorrect as it does not result from the correct calculation. Choice C (1.5 mL) is incorrect as it is not the result of dividing the ordered dose by the concentration. Choice D (0.65 mL) is incorrect as it is not the accurate calculation based on the provided information.

5. When inspecting the client's eyelids for ptosis, the nurse is checking for which abnormality?

• A. Drooping
• B. Pupil dilation
• C. Pupil constriction
• D. Deviation of ocular movements

Correct answer: A

Rationale: When a nurse inspects a client's eyelids for ptosis, they are checking for drooping. Ptosis is a condition characterized by the drooping of the eyelids and can be associated with various disorders such as myasthenia gravis, dysfunction of cranial nerve III, and Bell's palsy. Pupil dilation and constriction are assessed using a flashlight to check pupillary response. Deviation of ocular movements is evaluated by leading the client's eyes through the six cardinal positions of gaze. Therefore, in this scenario, the correct answer is 'Drooping' as it specifically relates to the abnormality associated with ptosis.

Similar Questions