Nursing Elites

1. A client is receiving morphine via PCA infusion device after abdominal surgery. Which of the following statements indicates that the client knows how to use the device?

• A. I'll wait to use the device until it's absolutely necessary.
• B. I'll be careful about pushing the button too much to avoid an overdose.
• C. I should tell the nurse if the pain doesn't stop while I am using this device.
• D. I will ask my adult child to push the dose button when I am sleeping.

Correct answer: C

Rationale: Choice C is the correct answer because it demonstrates that the client understands the importance of communicating with the nurse if the pain persists while using the PCA device. This is crucial as it ensures proper pain management and monitoring. Choices A and B are incorrect because delaying the use of the device until necessary or being cautious about pushing the button too much do not necessarily reflect understanding of using the PCA device effectively. Choice D is incorrect as having someone else, like an adult child, push the dose button goes against the principle of the client self-administering the medication through the PCA device.

2. A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

• A. I will only have to wear this for 6 months.
• B. I should inspect my skin daily.
• C. The brace will be worn day and night.
• D. I can take it off when I shower.

Correct answer: A

Rationale: The correct answer is A. The statement 'I will only have to wear this for 6 months' indicates a need for additional teaching because the Milwaukee Brace is typically worn for 12-18 months, not just 6 months. Choice B is correct as inspecting the skin daily is important to prevent skin breakdown. Choice C is correct as the brace is usually worn day and night for effectiveness. Choice D is correct as the brace can be removed when showering to maintain hygiene.

3. A client with a history of falls is under the care of a nurse. Which of the following actions should be the nurse’s priority?

• A. Complete a fall-risk assessment.
• B. Educate the client and family about fall risks.
• C. Eliminate safety hazards from the client’s environment.
• D. Ensure the client uses assistive aids in their possession.

Correct answer: C

Rationale: The nurse's priority should be to eliminate safety hazards from the client's environment as it directly reduces the risk of falls. Addressing environmental hazards is an immediate and crucial step in preventing falls. While completing a fall-risk assessment is important to understand the client's risk factors, educating the client and family about fall risks is essential for prevention, and ensuring the use of assistive aids is crucial for safety, eliminating safety hazards takes precedence as it directly mitigates the risk of falls.

4. A client who is postoperative and has paralytic ileus is being cared for by a nurse. Which of the following abdominal assessments should the nurse expect?

• A. Absent bowel sounds with distention
• B. Hyperactive bowel sounds
• C. Normal bowel sounds
• D. High-pitched bowel sounds

Correct answer: A

Rationale: In a client with paralytic ileus, absent bowel sounds with distention are expected due to decreased or absent bowel motility. This is a key characteristic of paralytic ileus, where the bowel is unable to contract and move contents along the digestive tract. Hyperactive bowel sounds (choice B) are more indicative of increased peristalsis, which is not typically seen in paralytic ileus. Normal bowel sounds (choice C) may not be present in a client with paralytic ileus. High-pitched bowel sounds (choice D) are not typically associated with paralytic ileus. Therefore, the correct assessment finding in this scenario is absent bowel sounds with distention.

5. The patient refuses to bathe in the morning, stating a preference for evening baths. What is the best action for the nurse?

• A. Defer the bath until evening and pass on the information to the next shift.
• B. Tell the patient that daily morning baths are part of the 'normal' routine.
• C. Explain the importance of maintaining morning hygiene practices.
• D. Cancel hygiene for the day and attempt again in the morning.

Correct answer: A

Rationale: The best action by the nurse is to respect the patient's preference and autonomy. Defer the bath until evening to allow the patient to follow their usual hygiene routine. Passing on the information to the next shift ensures continuity of care. Choice B is incorrect because it disregards the patient's preference and autonomy. Choice C, while important, does not address the patient's immediate concern. Choice D is incorrect as it does not respect the patient's wishes and may lead to further resistance to bathing.

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