Nursing Elites

1. What is the best method to assess pain in a non-verbal patient?

• A. Observe for facial expressions
• B. Observe for restlessness
• C. Observe for sweating
• D. Check for non-verbal cues

Correct answer: A

Rationale: The correct answer is to observe for facial expressions when assessing pain in a non-verbal patient. Facial expressions can provide vital clues about the patient's pain level and discomfort. Choices B and C, observing for restlessness and sweating, can be less specific and may indicate other issues besides pain. Choice D, checking for non-verbal cues, is too broad and does not specify the crucial aspect of focusing on facial expressions.

2. A client has a new diagnosis of hypertension and is being taught about lifestyle changes by a nurse. Which of the following instructions should the nurse include?

• A. Increase your sodium intake to 3,000 mg per day.
• B. Exercise for 30 minutes at least 5 days a week.
• C. Sleep for at least 10 hours each night.
• D. Limit your fluid intake to 1 liter per day.

Correct answer: B

Rationale: The correct answer is B: "Exercise for 30 minutes at least 5 days a week." Regular exercise helps promote cardiovascular health and manage hypertension. Choice A is incorrect because increasing sodium intake is not recommended for hypertension. Choice C is incorrect because while sleep is important, excessive sleep duration is not typically part of hypertension management. Choice D is incorrect because fluid intake should be adequate unless advised otherwise by a healthcare provider.

3. A nurse is caring for a 5-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?

• A. Your baby needs an IV because she is not producing any tears
• B. Your baby needs an IV because her fontanels are bulging
• C. Your baby needs an IV because she is breathing slower than normal
• D. Your baby needs an IV because her heart rate is decreasing

Correct answer: A

Rationale: The correct answer is A. A lack of tear production is a sign of severe dehydration in infants, indicating the need for IV therapy. Option B, bulging fontanels, is a sign of increased intracranial pressure, not dehydration. Option C, breathing slower than normal, and Option D, decreasing heart rate, are not specific signs of severe dehydration that would indicate the need for IV therapy in this case.

4. A client has a new prescription for nitroglycerin sublingual tablets. Which of the following instructions should the nurse include?

• A. Take the medication with a full glass of water.
• B. Take the medication with food to prevent stomach upset.
• C. Take one tablet every 5 minutes, up to three doses, for chest pain.
• D. Swallow the tablet whole for the best effect.

Correct answer: C

Rationale: The correct instruction for a client with a new prescription for nitroglycerin sublingual tablets is to take one tablet every 5 minutes, up to three doses, for chest pain. This dosing regimen helps relieve chest pain associated with angina by promoting vasodilation. Option A is incorrect as nitroglycerin sublingual tablets should be placed under the tongue, not swallowed with water. Option B is incorrect because taking nitroglycerin with food may decrease its effectiveness. Option D is incorrect because nitroglycerin sublingual tablets are meant to be dissolved under the tongue, not swallowed whole.

5. A nurse is caring for a client who has cirrhosis. Which of the following findings should the nurse expect?

• A. Decreased bilirubin levels
• B. Decreased prothrombin time
• C. Decreased albumin levels
• D. Increased prothrombin time

Correct answer: D

Rationale: In clients with cirrhosis, the liver is unable to produce clotting factors efficiently, leading to impaired clotting function. Therefore, an increased prothrombin time is expected in cirrhosis. Choices A, B, and C are incorrect. Decreased bilirubin levels are not typically seen in cirrhosis; prothrombin time is usually increased, not decreased; and albumin levels are often decreased in cirrhosis due to reduced synthetic liver function.

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