Nursing Elites

1. A charge nurse is explaining the various stages of the lifespan to a group of newly licensed nurses. Which of the following examples should the nurse include as a developmental task for middle adulthood?

• A. The client evaluates their behavior after a social interaction.
• B. The client states they are learning to trust others.
• C. The client wishes to find meaningful friendships.
• D. The client expresses concerns about the next generations.

Correct answer: D

Rationale: The correct answer is D because in middle adulthood, individuals often shift their focus towards concerns related to the next generations. They reflect on their roles in guiding and supporting the younger generations. Choice A is incorrect as evaluating behavior after a social interaction is more relevant to self-awareness, which is not a specific developmental task for middle adulthood. Choice B, learning to trust others, is more commonly associated with early adulthood tasks related to forming intimate relationships. Choice C, wishing to find meaningful friendships, is more aligned with tasks associated with young adulthood and social connections.

2. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the nurse implement first?

• A. Check the drainage tubing for a kink
• B. Review the intake and output record
• C. Notify the healthcare provider
• D. Give the client 8 oz of water to drink

Correct answer: A

Rationale: The correct answer is to check the drainage tubing for a kink. A kink in the tubing can obstruct urine flow, potentially causing the low output. By addressing this first, the nurse can ensure that there are no physical obstructions hindering urine drainage. Reviewing the intake and output record is important, but addressing a possible kink in the tubing takes precedence as it directly affects urine flow. Notifying the healthcare provider should be considered after assessing and resolving immediate issues. Giving the client water to drink may be appropriate, but addressing a kink in the tubing is the priority to ensure proper function of the urinary catheter.

3. Before digital removal of a fecal impaction, which type of enema should the nurse give to loosen the feces?

• A. Oil Retention
• B. Saline
• C. Soapy Water
• D. Hypertonic

Correct answer: A

Rationale: An oil retention enema containing mineral oil is the most suitable choice to help soften and loosen a fecal impaction before digital removal. Mineral oil lubricates and softens the stool, facilitating passage. Saline enemas draw water into the colon to promote bowel movements but may not effectively soften a fecal impaction. Soapy water enemas are primarily for cleansing, not softening stool. Hypertonic enemas eliminate fluid from the body and are not appropriate for loosening fecal impactions.

4. While a client is receiving total parenteral nutrition (TPN), which of the following actions should the nurse take?

• A. Monitor the client's blood glucose level every 4 hours.
• B. Change the TPN tubing every 72 hours.
• C. Weigh the client daily.
• D. Change the TPN bag every 24 hours.

Correct answer: D

Rationale: The correct action is to change the TPN bag every 24 hours to reduce the risk of infection. Changing the TPN tubing every 72 hours (Choice B) may increase the risk of contamination. Monitoring the client's blood glucose level every 4 hours (Choice A) is important but not specific to TPN administration. Weighing the client daily (Choice C) is essential for monitoring fluid status but is not directly related to TPN administration.

5. A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client’s pain?

• A. Ask the client what precipitates the pain.
• B. Question the client about the location of the pain.
• C. Offer the client a pain scale to measure their pain.
• D. Use open-ended questions to identify the client’s pain sensations.

Correct answer: C

Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client’s pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.

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