Nursing Elites

1. The nurse is planning care for a client with end-stage lung cancer. The client expresses concern about ongoing pain management. Which nursing action is most appropriate to include in the plan of care?

• A. Consult the healthcare provider for recommendations on pain management
• B. Schedule the client for physical therapy to manage pain
• C. Recommend the client attend a support group for cancer patients
• D. Suggest alternative therapies like acupuncture or massage

Correct answer: A

Rationale: Consulting the healthcare provider for recommendations on pain management is the most appropriate action. The healthcare provider can assess the client's pain, prescribe appropriate medications, and adjust the pain management plan as needed. In end-stage cancer, managing pain often requires pharmacological interventions that the healthcare provider can best provide. Physical therapy (choice B) may not be the primary intervention for pain management in end-stage cancer. While attending a support group (choice C) can provide emotional support, it does not directly address the client's pain management concerns. Suggesting alternative therapies (choice D) is not the initial step; consulting the healthcare provider should come first to ensure a comprehensive and tailored pain management plan.

2. While flushing the proximal port of a triple lumen central venous catheter with heparin solution, the nurse meets resistance. What action should the nurse take?

• A. Remove the cap and apply direct gentle pressure with the syringe
• B. Contact the healthcare provider regarding the need for a chest x-ray
• C. Cover the cap with tape and label the port as being obstructed
• D. Remove the catheter while applying gentle pressure at the insertion site

Correct answer: B

Rationale: When encountering resistance while flushing a central venous catheter, it is crucial to contact the healthcare provider regarding the need for a chest x-ray. This resistance may indicate a blockage within the catheter, a kink, or other issues that could compromise the integrity of the catheter or pose a risk to the patient. It is essential to assess the situation through imaging to determine the appropriate course of action. Option A is incorrect because applying direct pressure could cause damage to the catheter or dislodge any potential blockage. Option C is incorrect as labeling the port as obstructed without further assessment may delay necessary interventions. Option D is incorrect as removing the catheter without proper evaluation can lead to complications and should only be done under the guidance of a healthcare provider.

3. When designing a plan of care for a client diagnosed with pheochromocytoma, a goal statement should be prepared that relates to which topic?

• A. Psychological counseling to address emotional well-being
• B. Medication teaching concerning adrenergic blockers
• C. Preoperative and postoperative teaching for adrenalectomy
• D. Education on dietary modifications for hypertension

Correct answer: C

Rationale: The correct answer is C: Preoperative and postoperative teaching for adrenalectomy. Pheochromocytoma often requires adrenalectomy as part of the treatment plan. Therefore, educating the client about what to expect before and after the surgery is crucial for optimal care and outcomes. Choices A, B, and D are incorrect. Choice A focuses on emotional well-being rather than the specific surgical intervention needed for pheochromocytoma. Choice B is unrelated as the primary treatment for pheochromocytoma is surgical rather than medication-based. Choice D, though related to managing hypertension, does not address the surgical aspect of treating pheochromocytoma.

4. When assessing a client several hours after surgery, the nurse observes that the client grimaces and guards the incision while moving in bed. The client is diaphoretic, has a radial pulse rate of 110 beats/min, and a respiratory rate of 35 breaths/min. What assessment should the nurse perform first?

• A. Apical heart rate
• B. IV site and fluids
• C. Pain scale
• D. Temperature

Correct answer: C

Rationale: The client’s grimacing and guarding suggest pain; assessing the pain scale is crucial for addressing the discomfort. Pain management is a priority to ensure the client's well-being and comfort. Checking the apical heart rate, IV site and fluids, or temperature can be important but addressing the client's pain takes precedence in this scenario. The elevated pulse rate and respiratory rate could be indicative of pain, making the pain scale assessment essential to guide appropriate interventions.

5. A male client approaches the nurse with an angry expression on his face and raises his voice, saying, “My roommate is the most selfish, self-centered, angry person I have ever met. If he loses his temper one more time with me, I am going to punch him out.” The nurse recognizes that the client is using which defense mechanism?

• A. Denial
• B. Splitting
• C. Projection
• D. Rationalization

Correct answer: C

Rationale: The client is projecting his feelings of anger and frustration onto his roommate, attributing his own feelings to the other person. Projection is a defense mechanism where individuals attribute their thoughts, feelings, or motives onto another person. In this scenario, the client is displacing his anger onto his roommate, thereby using projection as a defense mechanism. Denial (choice A) is refusing to acknowledge an aspect of reality. Splitting (choice B) involves viewing people as all good or all bad. Rationalization (choice D) is creating logical explanations to justify unacceptable behavior.

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