Nursing Elites

1. A client is prescribed tramadol for pain management. Which of the following should the nurse educate the client about?

• A. It is a non-opioid analgesic
• B. It can cause sedation
• C. It has no risk for dependence
• D. It can be taken as needed

Correct answer: B

Rationale: The correct answer is B. Tramadol can cause sedation, so the nurse should educate the client about this potential side effect. Choice A is incorrect because tramadol is actually an opioid analgesic. Choice C is incorrect as tramadol does carry a risk for dependence, especially with prolonged use. Choice D is not entirely accurate as tramadol is usually prescribed on a scheduled basis rather than as needed.

2. A nurse is caring for a client receiving oxytocin IV for labor augmentation. The client’s contractions are occurring every 45 seconds and lasting 90 seconds. What action should the nurse take?

• A. Discontinue the oxytocin infusion
• B. Increase the oxytocin infusion
• C. Decrease the oxytocin infusion
• D. Maintain the oxytocin infusion

Correct answer: A

Rationale: In this scenario, the client is experiencing uterine hyperstimulation with contractions every 45 seconds lasting 90 seconds. This frequency and duration of contractions can lead to fetal distress. The appropriate nursing action is to discontinue the oxytocin infusion immediately to prevent complications. Increasing or maintaining the oxytocin infusion would exacerbate the situation, while decreasing it may not be sufficient to address the issue effectively.

3. A nurse is assessing a client who had a stroke and is showing signs of dysphagia. Which finding indicates this condition?

• A. Abnormal mouth movements
• B. Inability to stand without assistance
• C. Paralysis of the right arm
• D. Loss of appetite

Correct answer: A

Rationale: Abnormal mouth movements are a key sign of dysphagia, a condition commonly seen in stroke clients. Dysphagia refers to difficulty swallowing, which can manifest as abnormal movements of the mouth during eating or drinking. In stroke patients, dysphagia increases the risk of aspiration, where food or liquids enter the airway instead of the esophagus, leading to potential complications such as pneumonia. Choices B, C, and D are not directly indicative of dysphagia. Inability to stand without assistance may indicate motor deficits, paralysis of the right arm suggests a neurological impairment, and loss of appetite can be a non-specific symptom in many conditions but does not specifically point to dysphagia.

4. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

• A. Initiate a dietary consult for a toddler
• B. Administer a glycerin suppository to a preschool-age child
• C. Evaluate gastric residual following intermittent feeding of an adolescent
• D. Transport a school-age child to x-ray

Correct answer: D

Rationale: The correct answer is D because transporting a stable child to x-ray is a task that can be safely delegated to an assistive personnel. This task does not require clinical judgment or specialized skills. Choices A, B, and C involve assessments and interventions that require nursing judgment and should be performed by a qualified nurse. Initiating a dietary consult for a toddler involves assessing the child's nutritional needs and must be done by a nurse. Administering a glycerin suppository to a preschool-age child requires medication administration skills and knowledge of appropriate dosages, which are within the nurse's scope of practice. Evaluating gastric residual following intermittent feeding of an adolescent is a clinical assessment that requires interpretation and decision-making based on the findings, making it a nursing responsibility.

5. A client tells the nurse that she suspects she is pregnant because she is able to feel the baby move. The nurse knows that this is a:

• A. Presumptive sign of pregnancy
• B. Probable sign of pregnancy
• C. Positive sign of pregnancy
• D. Possible sign of pregnancy

Correct answer: A

Rationale: The correct answer is A: Presumptive sign of pregnancy. Quickening, or the sensation of fetal movement, is considered a presumptive sign of pregnancy. It is not definitive because other conditions, such as gas or intestinal movement, can mimic the feeling of fetal movement. Choice B, Probable sign of pregnancy, refers to signs that make the nurse reasonably certain that a woman is pregnant, such as a positive pregnancy test. Choice C, Positive sign of pregnancy, includes signs like hearing fetal heart tones or visualizing the fetus on ultrasound, which definitively confirm pregnancy. Choice D, Possible sign of pregnancy, is a vague term and does not specifically relate to any pregnancy sign.

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