Nursing Elites

1. When assessing a client with chronic pain, which of the following is the most reliable indicator of the client's pain?

• A. The client's vital signs.
• B. The client's self-report of pain.
• C. The client's body language.
• D. The client's medical history.

Correct answer: B

Rationale: The client's self-report of pain is the most reliable indicator of pain. Pain is a subjective experience, and the client's self-report provides direct insight into their perception of pain intensity, quality, and impact on daily life. Vital signs, body language, and medical history can offer additional information but may not accurately reflect the client's actual pain experience. Therefore, relying on the client's self-report ensures a more accurate assessment of their pain and helps in tailoring appropriate interventions and treatment plans.

2. A client with celiac disease is being taught about dietary management. Which statement by the client indicates an understanding of the teaching?

• A. I should avoid foods that contain gluten.
• B. I should increase my intake of foods high in gluten.
• C. I should avoid foods that contain lactose.
• D. I should increase my intake of foods high in lactose.

Correct answer: A

Rationale: The correct answer is A: 'I should avoid foods that contain gluten.' Celiac disease requires the avoidance of gluten-containing foods to manage symptoms and prevent complications. Gluten is found in wheat, barley, and rye. Choices B, C, and D are incorrect as they do not align with the dietary requirements for managing celiac disease. Increasing intake of foods high in gluten or lactose would be detrimental for someone with celiac disease.

3. A healthcare professional is preparing to administer an intradermal injection. Which of the following actions should the professional take?

• A. Use a tuberculin syringe.
• B. Insert the needle at a 45-degree angle.
• C. Use a 1-inch needle.
• D. Aspirate before injecting.

Correct answer: A

Rationale: When administering an intradermal injection, a tuberculin syringe is the appropriate choice due to its small size and precise measurement markings, which are essential for accurately delivering the medication into the dermis layer of the skin. Using a 1-inch needle (choice C) is more common for subcutaneous injections, while inserting the needle at a 45-degree angle (choice B) is typical for intramuscular injections. Aspirating before injecting (choice D) is not necessary for intradermal injections, as the goal is to deliver the medication into the dermis rather than a blood vessel.

4. What is the primary purpose of therapeutic communication in healthcare?

• A. To gather client information.
• B. To provide client education.
• C. To establish a therapeutic relationship.
• D. To document client care.

Correct answer: C

Rationale: The primary purpose of therapeutic communication in healthcare is to establish a therapeutic relationship between the healthcare provider and the client. Through effective communication, trust, empathy, and understanding can be fostered, which are essential for providing quality care and promoting positive health outcomes. Building a therapeutic relationship enhances patient satisfaction, improves adherence to treatment plans, and increases the likelihood of successful health outcomes.

5. A client is receiving continuous enteral feedings through a nasogastric tube. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30°
• B. Flush the tube with 50 mL of water every 2 hours
• C. Replace the feeding bag and tubing every 72 hours
• D. Check the client's gastric residual every 8 hours

Correct answer: A

Rationale: Elevating the head of the bed to 30° is the correct action to take when a client is receiving continuous enteral feedings through a nasogastric tube. This position helps prevent aspiration of the enteral feedings into the lungs, reducing the risk of aspiration pneumonia. Additionally, elevating the head of the bed promotes proper digestion and absorption of the feedings by utilizing gravity to facilitate movement into the stomach and through the gastrointestinal tract. Flushing the tube with water every 2 hours (Choice B) is not necessary for continuous feedings and may disrupt the feeding schedule. Replacing the feeding bag and tubing every 72 hours (Choice C) is not the standard recommendation unless there are specific concerns or complications. Checking the client's gastric residual every 8 hours (Choice D) is important but not the immediate action needed to prevent aspiration during enteral feedings.

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