Nursing Elites

1. A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0-10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?

• A. "It might help me to listen to music while I'm lying in bed."
• B. "I will use the pain medication as prescribed to manage the pain."
• C. "I will request a different type of pain medication if the pain persists."
• D. "I will ask for a physical therapist to help with the pain."

Correct answer: A

Rationale: The correct answer is A. Listening to music is a non-pharmacological method to help manage mild pain, reflecting an understanding of pain management strategies. It shows the client's grasp of non-pharmacological pain management techniques taught preoperatively. Choice B, while important, only addresses pharmacological pain management, omitting other strategies discussed in preoperative teaching. Choice C jumps to changing medications without considering non-pharmacological methods first, indicating a narrow approach to pain management. Choice D involves a physical therapist, which is not directly related to the pain management strategies typically discussed in preoperative teaching.

2. A nurse in a provider's office is obtaining the health and medication history of a client who has a respiratory infection. The client tells the nurse that she is not aware of any allergies, but that she did develop a rash the last time she was taking an antibiotic. Which of the following information should the nurse give the client?

• A. "Rashes are very common, especially if you have dry skin. Did it go away on its own?"
• B. "Virtually all medications have adverse effects. It sounds like this could have been an adverse effect of the antibiotic."
• C. "It's unlikely that your doctor will prescribe an antibiotic for what seems to be a minor viral infection, so we shouldn't be concerned about that rash."
• D. "We need to document the exact medication you were taking because you might be allergic to it."

Correct answer: D

Rationale: The correct answer is D. If a client reports developing a rash when taking a specific medication, even if they are not aware of any allergies, it is crucial to document this information. This is necessary to prevent future allergic reactions. Identifying the exact medication that caused the rash is essential as the client could have an allergy to it. Providing this information allows healthcare providers to avoid prescribing the same medication again, which could potentially lead to more severe allergic reactions or life-threatening situations. Choices A, B, and C are incorrect because they do not address the importance of documenting the specific medication that caused the adverse reaction or the potential risks of repeating the medication. Simply attributing the rash to common occurrences, adverse effects of medications in general, or assuming the rash is insignificant in the current context can overlook the critical aspect of identifying and avoiding allergens.

3. A nurse is in a public building when someone cries out, 'Help! I think he is having a heart attack!' The nurse responds to the scene and finds the unconscious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after ensuring someone has called for EMS, should be to:

• A. Administer cardiac compressions
• B. Attach the AED pads to the client
• C. Check for a pulse
• D. Perform rescue breaths

Correct answer: A

Rationale: In a scenario where a person is unconscious and there is an indication of a possible heart attack, the immediate priority for the nurse should be to administer cardiac compressions. This action helps maintain circulation and ensures oxygenated blood reaches vital organs until the AED is available. Checking for a pulse or performing rescue breaths may delay essential circulation support, and attaching AED pads should follow the initial step of administering compressions to maximize the chances of a successful resuscitation.

4. Which assessment data reflects the need for nurses to include the problem, “Risk for falls,” in a client’s plan of care?

• A. Recent serum hemoglobin level of 16 g/dL
• B. Opioid analgesic received one hour ago
• C. Stooped posture with an unsteady gait
• D. Expressed feelings of depression

Correct answer: B

Rationale: The correct answer is B. The recent administration of opioid analgesics increases the risk for falls due to potential side effects such as sedation and dizziness. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk for falls. Choice C, stooped posture with an unsteady gait, may indicate an existing risk but does not directly reflect the need to include 'Risk for falls' in the care plan. Choice D, expressed feelings of depression, is important to address but is not directly associated with the risk for falls.

5. When ethical dilemmas arise, what should newly licensed nurses expect and identify as an ethical dilemma?

• A. A nurse on a medical-surgical unit demonstrates signs of chemical impairment.
• B. A nurse overhears another nurse telling an older adult client that if he doesn’t stay in bed, she will have to apply restraints.
• C. A family has conflicting feelings about the initiation of enteral tube feedings for their father, who is terminally ill.
• D. A client who is terminally ill hesitates to name their partner on their durable power of attorney form.

Correct answer: C

Rationale: An ethical dilemma involves a situation where there are conflicting values or principles that make it difficult to make a clear decision. In the given scenarios, option C best represents an ethical dilemma as the family has conflicting feelings about initiating enteral tube feedings for their terminally ill father. This situation presents a clash between different values and beliefs, making it challenging to reach a resolution. Options A, B, and D do not illustrate conflicting values or principles that characterize an ethical dilemma. Option A describes a nurse's impairment, which is a concern but not a direct ethical dilemma. Option B depicts a potential breach of client autonomy and restraint use, which is an ethical issue but not a true ethical dilemma. Option D involves a client's personal decision regarding a durable power of attorney form, which, although important, does not present conflicting values or principles that define an ethical dilemma.

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