Nursing Elites

1. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first?

• A. Divert the client’s attention
• B. Call for additional help from staff
• C. Document the planned action
• D. Re-assess the client's situation

Correct answer: D

Rationale: Before providing care to an anxious client, it is crucial for the nurse to first re-assess the client's situation. By re-assessing, the nurse can understand the underlying cause of the client's anxiety, which will help in tailoring appropriate care interventions. Re-assessment ensures that care provided is individualized and addresses the client's specific needs, promoting effective and client-centered care delivery. Diverting the client’s attention (Choice A) may not address the root cause of the anxiety. Calling for additional help (Choice B) may be necessary in some situations but should not be the first action. Documenting the planned action (Choice C) should come after re-assessing the client's situation to ensure accurate documentation based on the current assessment.

2. A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?

• A. Explain the potential respiratory issues associated with morphine use.
• B. Educate the family on assessing the effectiveness of analgesics.
• C. Suggest requesting a patient-controlled analgesic (PCA) pump from the healthcare provider.
• D. Provide the client with a schedule for around-the-clock prescribed analgesic use.

Correct answer: D

Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.

3. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled 'opened' and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

• A. Use the normal saline solution once more and then discard.
• B. Obtain a new sterile syringe to draw up the labeled saline solution.
• C. Use the saline solution and then relabel the bottle with the current date.
• D. Discard the saline solution and obtain a new unopened bottle.

Correct answer: D

Rationale: When performing sterile wound care, it is essential to use only newly opened and unexpired solutions to maintain sterility and prevent infections. The normal saline solution obtained by the nurse is labeled 'opened' and dated 48 hours prior to the current date, making it no longer considered sterile. The best action for the nurse to take in this situation is to discard the saline solution and obtain a new unopened bottle to ensure the safety and effectiveness of wound care. Choices A, B, and C are incorrect because reusing an already opened and outdated solution or attempting to relabel it with a current date can compromise patient safety and increase the risk of infection.

4. A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?

• A. Epigastric pain that radiates to the back.
• B. Abdominal pain with guarding.
• C. Nausea and vomiting.
• D. Increased bowel sounds in all quadrants.

Correct answer: A

Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. While abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis, they are less specific and may be seen in various other gastrointestinal conditions. Therefore, the most indicative finding for acute pancreatitis is epigastric pain that radiates to the back.

5. The healthcare provider plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the provider:

• A. Work on establishing rapport with the patient.
• B. Use humor to lighten emotionally charged topics of discussion.
• C. Empathize with the patient when the patient shares sad feelings.
• D. Demonstrate respect when discussing emotionally charged topics.

Correct answer: D

Rationale: In fostering a therapeutic relationship, demonstrating respect is essential as it helps the patient feel valued and understood. Respectful communication contributes to building trust and a safe environment for open and honest discussions.

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