Nursing Elites

1. Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?

• A. Sensory pattern, area, intensity, and nature of the pain.
• B. Identification of trigger points through palpation and manual pressure on painful areas.
• C. Current schedule and total dosages of medications used for breakthrough pain.
• D. Assessment of sympathetic responses indicative of acute pain onset.

Correct answer: A

Rationale: The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.

2. The client is being taught how to self-administer a subcutaneous injection. To ensure sterility of the procedure, which subject is most important for the instructor to include in the teaching plan?

• A. Hand washing before preparing the injection.
• B. Technique for drawing medication from a vial.
• C. Selection and rotation of injection sites.
• D. Proper disposal of injection equipment.

Correct answer: B

Rationale: To maintain the sterility of the procedure, it is crucial to teach the client the correct technique for drawing medication from a vial. This ensures that the medication remains sterile during preparation and administration. While hand washing, injection site selection, and equipment disposal are important aspects of injection safety, the key focus should be on maintaining the sterility of the medication itself to prevent infections and ensure the effectiveness of the treatment.

3. When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?

• A. Position the client supine for a few minutes
• B. Assist the client to stand at the bedside
• C. Apply the blood pressure cuff securely
• D. Record the client’s pulse rate and rhythm

Correct answer: A

Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.

4. The client with cholecystitis is being instructed on dietary choices. Which meal best meets the dietary needs of this client?

• A. Steak, baked beans, and a salad
• B. Broiled fish, green beans, and an apple
• C. Pork chops, macaroni and cheese, and grapes
• D. Avocado salad, milk, and angel food cake

Correct answer: B

Rationale: Cholecystitis requires a low-fat diet to reduce stress on the gallbladder. The meal of broiled fish, green beans, and an apple aligns with this dietary recommendation by providing lean protein and low-fat, high-fiber foods that are easier for the body to digest, making it the most suitable choice for a client with cholecystitis.

5. Which assessment data indicates the need for the nurse 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 administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client’s care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.

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