Nursing Elites

1. A nurse is observing a newly licensed nurse providing care for a client who reports pain. The nurse checked the client’s MAR and noted the last dose of pain medication was administered 6 hours ago. The prescription specifies administration every 4 hours PRN for pain. The nurse administered the medication and followed up with the client 40 minutes later, who reported improvement. What did the newly licensed nurse overlook in the nursing process?

• A. Assessment
• B. Planning
• C. Intervention
• D. Evaluation

Correct answer: A

Rationale: The correct answer is 'Assessment.' In the nursing process, assessment is the first step, crucial before any intervention. Assessment involves gathering data about the client's condition to establish a baseline for evaluating responses to interventions. In this scenario, the newly licensed nurse missed assessing the client's pain intensity, location, quality, and other relevant factors before administering the pain medication. While the follow-up evaluation with the client is commendable, it cannot replace the initial assessment. Planning involves setting goals and outcomes, intervention is the action taken to achieve these goals, and evaluation assesses the client's response to the intervention.

2. Which goal is most appropriate for a patient who has had a total hip replacement?

• A. The patient will ambulate briskly on the treadmill by the time of discharge.
• B. The patient will walk 100 feet using a walker by the time of discharge.
• C. The nurse will assist the patient to ambulate in the hall 2 times a day.
• D. The patient will ambulate by the time of discharge.

Correct answer: B

Rationale: The goal 'The patient will walk 100 feet using a walker by the time of discharge' is the most appropriate goal for a patient who has had a total hip replacement because it is specific, measurable, achievable, and individualized. This goal sets a clear target for the patient's mobility progress post-surgery. Choice A is too vague and does not provide a specific target distance or method of ambulation. Choice C focuses on the nurse's actions rather than the patient's progress. Choice D lacks specificity in terms of distance or assistance required, making it less measurable and individualized compared to Choice B.

3. The nurse is planning care for a 12-year-old child with sickle cell disease in a vaso-occlusive crisis affecting the elbow. Which one of the following should be the priority?

• A. Limiting fluids
• B. Client-controlled analgesia
• C. Applying cold compresses to the elbow
• D. Performing passive range of motion exercises

Correct answer: B

Rationale: During a vaso-occlusive crisis in sickle cell disease, the priority intervention is effective pain management. Client-controlled analgesia allows the child to self-administer pain relief as needed, promoting comfort and reducing stress. Limiting fluids (choice A) is not appropriate in this scenario as hydration is essential to prevent complications. Cold compresses (choice C) may provide some comfort but do not address the underlying pain. Passive range of motion exercises (choice D) are contraindicated during a vaso-occlusive crisis due to the risk of further pain and tissue damage.

4. A caregiver of an immobile client requiring assistance with repositioning is being taught by a nurse on preventing back strain. Which statement by the caregiver indicates an understanding of the teaching?

• A. I will place the bed in the lowest position
• B. I will tighten my abdominal muscles prior to moving
• C. I will keep my legs straight to provide more power in the lift
• D. I will twist at the waist while pulling the draw sheet

Correct answer: B

Rationale: The correct answer is B. Tightening the abdominal muscles before moving helps protect the back by providing core support. Keeping the legs straight (choice C) is incorrect as bending the legs is recommended to provide a stable base and prevent strain on the back. Twisting at the waist (choice D) while moving can cause back injury due to the strain on the spine. Placing the bed in the lowest position (choice A) is not directly related to preventing back strain during client repositioning, although it may be necessary for other reasons.

5. A 3-year-old child is brought to the clinic by his grandmother to be seen for 'scratching his bottom and wetting the bed at night.' Based on these complaints, the nurse would initially assess for which problem?

• A. Allergies
• B. Scabies
• C. Regression
• D. Pinworms

Correct answer: D

Rationale: The correct answer is D, Pinworms. Pinworms are a common cause of itching around the anal area, especially at night, in young children. Scratching the bottom and bedwetting can be indicative of a pinworm infection. Allergies (Choice A) are less likely given the symptoms described. Scabies (Choice B) may cause itching but is less common in causing bedwetting. Regression (Choice C) is not a common cause of these specific symptoms in a 3-year-old child.

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