Nursing Elites

1. The nurse is caring for a client who is 4 hours post-operative from abdominal surgery. The client is complaining of severe pain. What is the nurse's first action?

• A. Reassess the pain and its characteristics
• B. Administer prescribed pain medication
• C. Notify the surgeon
• D. Encourage the use of relaxation techniques

Correct answer: A

Rationale: The correct first action for the nurse to take when a post-operative client complains of severe pain is to reassess the pain and its characteristics. Reassessment is crucial to understand the nature and intensity of the pain, which will guide the nurse in providing appropriate interventions. Administering pain medication may be necessary but should only be done after reassessment to ensure the right medication and dose are given. Notifying the surgeon may be required in certain situations, but reassessment of pain should precede this action. Encouraging relaxation techniques is not the priority when a client is experiencing severe pain post-operatively.

2. After receiving a report, the nurse receives the laboratory values for four clients. Which client requires the nurse’s immediate intervention? The client who is...

• A. Short of breath after a shower and has a hemoglobin of 8 grams
• B. Bleeding from a finger stick and has a prothrombin time of 30 seconds
• C. Febrile and has a WBC count of 14,000/mm3
• D. Trembling and has a glucose level of 50 mg/dL

Correct answer: D

Rationale: A glucose level of 50 mg/dL is indicative of hypoglycemia, which requires immediate intervention to prevent further complications. Hypoglycemia can lead to serious consequences such as altered mental status, seizures, and even coma if not promptly addressed. The other options do not present immediate life-threatening conditions that require urgent intervention. Shortness of breath with a hemoglobin of 8 grams may indicate anemia but does not require immediate intervention. Bleeding from a finger stick with a prothrombin time of 30 seconds may suggest clotting issues, which are important but not as immediately critical as hypoglycemia. Being febrile with an elevated WBC count could indicate infection, which is concerning but not as urgently critical as hypoglycemia.

3. The client with newly diagnosed peptic ulcer disease (PUD) is being taught about lifestyle modifications. Which instruction should be included?

• A. Increase the intake of spicy foods
• B. Avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs)
• C. Drink coffee in moderation
• D. Eat large meals at bedtime

Correct answer: B

Rationale: The correct instruction to include when teaching a client with newly diagnosed PUD about lifestyle modifications is to avoid the use of nonsteroidal anti-inflammatory drugs (NSAIDs). NSAIDs can exacerbate peptic ulcer disease by causing further irritation of the gastric mucosa. Increasing the intake of spicy foods (choice A) can aggravate the condition by irritating the stomach lining. Drinking coffee (choice C) can stimulate gastric acid secretion, which may worsen the symptoms of PUD. Eating large meals at bedtime (choice D) can also exacerbate PUD by increasing gastric acid production when the body is at rest, potentially leading to discomfort and symptoms.

4. A client's daughter phones the charge nurse to report that the night nurse did not provide good care for her mother. What response should the nurse make?

• A. Explain that all staff are doing their best
• B. Ask for a description of what happened during the night
• C. Tell the daughter to talk to the unit's nurse manager
• D. Reassure the daughter that the mother will get better care

Correct answer: B

Rationale: The correct response for the nurse in this situation is to ask for a description of what happened during the night. This allows the nurse to gather specific information about the care provided and address the complaint appropriately. Choice A is incorrect because dismissing the concern by stating that all staff are doing their best does not address the specific complaint. Choice C is not the best immediate response as the charge nurse should first gather information before escalating the issue to the nurse manager. Choice D is incorrect as it focuses on reassurance without addressing the reported issue.

5. The mother of an 8-year-old boy tells the nurse that he fell out of a tree and hurt his arm and shoulder. Which assessment finding is the most significant indicator of possible child abuse?

• A. The child looks at the floor when answering the nurse's questions
• B. The mother's version of the injury is different from the child's version
• C. The child has several abrasions on the chest and legs
• D. The mother refuses to answer questions about family history

Correct answer: B

Rationale: In cases of possible child abuse, discrepancies between the accounts given by the child and the parent are critical indicators. This inconsistency could suggest that the injury was not accidental and may be a result of abuse. Looking at the floor while answering questions or having abrasions on the body can be concerning but are not as direct indicators of abuse as conflicting stories between the child and the parent.

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