Nursing Elites

1. A nurse enters a client's room to administer a prescribed medication, and the client asks about the medication. What is the most appropriate response by the nurse?

• A. Give detailed information about the medication, including its potential side effects.
• B. Refer the client to the healthcare provider for more information.
• C. Give a brief explanation and administer the medication.
• D. Ask another nurse to explain the medication and proceed.

Correct answer: B

Rationale: The most appropriate response for the nurse when a client asks about a medication is to refer the client to the healthcare provider for more information. This ensures that the client receives accurate and detailed information from the appropriate source. Providing detailed information or a brief explanation as choices A and C suggest may not be within the nurse's scope of practice and could potentially lead to misinformation or confusion. Asking another nurse to explain the medication, as in choice D, may not guarantee accurate information, so it is best to involve the healthcare provider directly.

2. A nurse is caring for a child who is allergic to penicillin. The nurse should verify which of the following prescriptions with the provider?

• A. Amphotericin B
• B. Amoxicillin-clavulanate
• C. Erythromycin
• D. Gentamicin

Correct answer: B

Rationale: Amoxicillin-clavulanate is related to penicillin, and a cross-sensitivity could occur, so the provider should be consulted.

3. When caring for a patient with a colostomy, which nursing action is most important?

• A. Monitor the colostomy for signs of infection.
• B. Empty the colostomy bag when it is half full.
• C. Encourage the patient to eat smaller, more frequent meals.
• D. Apply a skin barrier to prevent irritation.

Correct answer: B

Rationale: Emptying the colostomy bag when it is half full is the most important nursing action when caring for a patient with a colostomy. This practice helps prevent leakage, reduces the risk of skin irritation, and promotes patient comfort. Monitoring for signs of infection (Choice A) is essential but not as crucial as maintaining proper colostomy care. Encouraging the patient to eat smaller, more frequent meals (Choice C) can be beneficial for colostomy patients but is not as critical as ensuring timely emptying of the colostomy bag. Applying a skin barrier to prevent irritation (Choice D) is important, but ensuring timely emptying of the colostomy bag takes precedence in preventing complications associated with a colostomy.

4. A nurse is caring for a client following an esophagogastroduodenoscopy (EGD). Which of the following assessments is the nurse's priority?

• A. Level of consciousness
• B. Pain
• C. Nausea
• D. Gag reflex

Correct answer: D

Rationale: The correct answer is assessing the gag reflex. This is the priority assessment following an EGD procedure to prevent aspiration. Checking the gag reflex helps ensure the client's airway protection. Assessing the level of consciousness is important, but ensuring the client can protect their airway takes precedence. Pain and nausea assessments are also essential but are secondary to maintaining airway patency.

5. The nurse is evaluating the effectiveness of guided imagery for pain management in a patient with second- and third-degree burns requiring extensive dressing changes. Which finding best indicates the effectiveness of guided imagery?

• A. The patient's need for analgesic medication decreases during the dressing changes.
• B. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.
• C. The patient asks for pain medication during the dressing changes only once throughout the procedure.
• D. The patient's facial expressions remain stoic during the procedure.

Correct answer: A

Rationale: The correct answer is A. A reduction in the need for analgesic medication indicates that guided imagery is effective in managing the patient's pain. Choices B, C, and D do not directly measure the effectiveness of guided imagery. A patient rating pain as 6 on a scale of 0 to 10, asking for pain medication once, or having stoic facial expressions may not necessarily reflect the impact of guided imagery on pain management.

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