Nursing Elites

1. You are teaching a client about the patient-controlled analgesia (PCA) planned for post-operative care. Which statement indicates further teaching may be needed by the client?

• A. ''I will be receiving continuous doses of medication.''
• B. ''I should call the nurse before I take additional doses.''
• C. ''I will call for assistance if my pain is not relieved.''
• D. ''The machine will prevent an overdose.''

Correct answer: B

Rationale: PCA allows patients to self-administer pain medication within prescribed limits, without the need to call the nurse before taking an additional dose. Choice B suggests a misunderstanding of how PCA works, as the patient should be educated that they can self-administer doses within the safety parameters set by the healthcare provider. Choices A, C, and D demonstrate proper understanding of PCA, hence are not indicative of needing further teaching.

2. What does the nurse perform to determine the family nursing problems/needs?

• A. goal setting
• B. family health care plan formulation
• C. assessment
• D. evaluation

Correct answer: C

Rationale: The correct answer is C: assessment. Assessment is the initial step in identifying family nursing problems/needs. During assessment, the nurse collects data to understand the family's health status, strengths, weaknesses, and potential areas for intervention. This process helps in developing an accurate picture of the family's situation. Choices A, B, and D are incorrect because goal setting, family health care plan formulation, and evaluation come after the assessment phase. Goal setting occurs once the issues are identified, the family health care plan is developed based on assessment findings, and evaluation is the final step to assess the effectiveness of the interventions implemented.

3. A client with multiple sclerosis is receiving baclofen (Lioresal). The nurse should monitor the client for which of the following side effects?

• A. Hypertension
• B. Muscle spasms
• C. Drowsiness
• D. Tachycardia

Correct answer: C

Rationale: The correct answer is C: Drowsiness. Baclofen, a muscle relaxant commonly used to treat conditions like multiple sclerosis, can cause drowsiness as a side effect. Monitoring for drowsiness is important to ensure the client's safety and well-being. Choice A, Hypertension, is incorrect because baclofen is not known to cause hypertension. Choice B, Muscle spasms, is not a common side effect of baclofen but rather the symptom it is used to treat. Choice D, Tachycardia, is also incorrect as baclofen is not associated with causing an increase in heart rate.

4. The RN at a migrant health center notes an increased incidence of dermatitis in seasonal farm workers at a local fruit farm. In response to this finding, what is the most important information for the RN to obtain as part of the community assessment?

• A. Availability of clean fresh water to wash hands after work.
• B. Proper housing
• C. Access to health care services
• D. Access to transportation

Correct answer: A

Rationale: The correct answer is A: Availability of clean fresh water to wash hands after work. Proper hand hygiene, including washing hands with clean water, is crucial in preventing dermatitis, especially in farm workers who are exposed to potential irritants in their work environment. While proper housing (choice B), access to health care services (choice C), and access to transportation (choice D) are important factors in overall community health, they are not directly linked to preventing dermatitis in this scenario.

5. The nurse is administering the measles, mumps, rubella (MMR) vaccine to a 12-month-old child during the well-baby visit. Which age range should the nurse advise the parents to plan for their child to receive the MMR booster based on the current recommendations and guidelines by the CDC?

• A. 13-18 years of age
• B. 11-12 years of age
• C. 18-24 months of age
• D. 4-6 years of age

Correct answer: D

Rationale: The correct answer is D: 4-6 years of age. The CDC recommends administering the MMR booster to children aged 4 to 6 years. This booster dose is essential to ensure continued immunity against measles, mumps, and rubella. Choices A, B, and C are incorrect because they do not align with the CDC guidelines for the age range of MMR booster administration.

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