Nursing Elites

1. What is an expected finding during the assessment of a client transitioning into a new role?

• A. The client's ability to express feelings of guilt
• B. Presence of suicidal or homicidal ideation
• C. Changes in coping skills over the past few weeks
• D. Client's involvement in community activities

Correct answer: B

Rationale: During a client's transition into a new role, the presence of suicidal or homicidal ideation should be assessed due to the increased risk associated with significant life changes. This finding could indicate a need for immediate intervention. While assessing the client's ability to express feelings of guilt is important, it may not be the most critical aspect during this specific assessment. Changes in coping skills over time are relevant but might not be the primary focus during a role transition assessment. The client's involvement in community activities, although beneficial for social support, is not directly related to the immediate concerns of assessing a client transitioning into a new role.

2. A healthcare provider writes a medication order that seems excessively high for the patient's condition. What is the nurse's first step?

• A. Administer the medication immediately.
• B. Hold the medication and consult the provider.
• C. Reduce the dose without consulting the provider.
• D. Administer the medication after double-checking with another nurse.

Correct answer: B

Rationale: The correct first step for the nurse when encountering a medication order that appears excessively high for the patient's condition is to hold the medication and consult the provider. Administering the medication immediately (Choice A) without clarification could pose a risk to the patient's safety. Reducing the dose without consulting the provider (Choice C) is not recommended as it may lead to suboptimal treatment. Administering the medication after double-checking with another nurse (Choice D) is not sufficient; consulting the provider directly is crucial to ensure the accuracy and safety of the medication order.

3. A healthcare provider is caring for a client who has heart failure and is prescribed enalapril. The provider should monitor the client for which of the following adverse effects?

• A. Hypertension
• B. Hypokalemia
• C. Hyperglycemia
• D. Hyperkalemia

Correct answer: D

Rationale: Corrected Question: When a client with heart failure is prescribed enalapril, monitoring for hyperkalemia is essential. Enalapril is an angiotensin-converting enzyme (ACE) inhibitor that can lead to an increase in potassium levels in the blood. This adverse effect can be serious and potentially life-threatening. Choices A, B, and C are incorrect because enalapril does not typically cause hypertension, hypokalemia, or hyperglycemia as adverse effects. It's essential for healthcare providers to be vigilant in monitoring potassium levels when clients are on ACE inhibitors like enalapril.

4. A healthcare provider is assessing a patient with chronic pain. Which finding is most concerning?

• A. The patient reports a pain level of 6 on a scale of 0 to 10.
• B. The patient is lying still and refuses to move.
• C. The patient's pain persists despite medication.
• D. The patient reports feeling anxious and restless.

Correct answer: C

Rationale: In the context of chronic pain management, the most concerning finding is when the patient's pain persists despite medication. This suggests inadequate pain control or the need for a re-evaluation of the treatment plan. Choices A, B, and D are not as concerning in this scenario. A pain level of 6 on a scale of 0 to 10 is moderate and may be manageable with appropriate interventions. Patients with chronic pain can sometimes lie still due to pain or other reasons, and anxiety and restlessness are common in individuals with pain conditions but may not necessarily indicate a critical issue like uncontrolled pain.

5. What is the nurse's priority intervention for a patient who has developed a pressure ulcer?

• A. Apply a dressing to the ulcer.
• B. Reposition the patient every 2 hours.
• C. Provide the patient with pain medication.
• D. Clean the ulcer with normal saline.

Correct answer: B

Rationale: The correct answer is to reposition the patient every 2 hours. Repositioning helps prevent the worsening of pressure ulcers by relieving pressure on affected areas and promoting blood circulation, which aids in healing. Applying a dressing (choice A) is important but not the priority compared to repositioning. Providing pain medication (choice C) is essential for comfort but does not address the root cause of the pressure ulcer. Cleaning the ulcer with normal saline (choice D) is part of wound care but does not take precedence over repositioning to prevent further tissue damage.

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