Nursing Elites

1. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

2. A provider prescribes cold application for a client who reports ankle joint stiffness. Which of the following assessment findings should the nurse identify as a contraindication to the application of cold?

• A. Capillary refill of 4 seconds
• B. 7.5 cm (3 in) diameter bruise on the ankle
• C. Warts on the affected ankle
• D. 2+ pitting edema

Correct answer: A

Rationale: The correct answer is A. Capillary refill of 4 seconds indicates poor circulation, which is a contraindication to cold application as it could worsen the condition by further reducing blood flow. Choice B, a 7.5 cm (3 in) diameter bruise on the ankle, does not directly contraindicate cold application but may need evaluation for possible underlying injuries. Choice C, warts on the affected ankle, do not necessarily contraindicate cold application. Choice D, 2+ pitting edema, is not a direct contraindication to cold application but may need to be addressed separately.

3. A client reports increased pain following physical therapy. Which of the following questions should the nurse ask to assess the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain feel like burning or aching?
• C. Is the pain constant or intermittent?
• D. Does the pain feel like throbbing or stabbing?

Correct answer: A

Rationale: When assessing pain quality, asking if the pain is sharp or dull helps determine the nature of the pain. Sharp pain is often associated with acute conditions, while dull pain may indicate a chronic issue. Choices B, C, and D are incorrect as they do not directly address the quality of the pain in terms of sharpness or dullness.

4. A young adult client is receiving instruction from a healthcare provider about health promotion and illness prevention. Which of the following statements indicates understanding?

• A. “I had my immunizations as a child, so I’m protected in that area.”
• B. “It is important to schedule routine health care visits even if I am feeling well.”
• C. “I will go to an urgent care center for my routine medical care.”
• D. “There’s no reason to seek help if I am feeling stressed as it’s just part of life.”

Correct answer: B

Rationale: The correct answer is B. Scheduling routine health care visits, even when feeling well, is crucial for early detection and prevention of health issues. This proactive approach allows healthcare providers to monitor overall health, provide preventive care, and address any emerging health concerns promptly. Choice A is incorrect because past immunizations do not cover all potential diseases; regular check-ups are still necessary. Choice C is incorrect as urgent care centers are not designed for routine medical care. Choice D is incorrect as seeking help for stress is important for mental well-being and should not be dismissed as a normal part of life.

5. A nurse is preparing to administer enoxaparin subcutaneously. Which of the following actions should the nurse take?

• A. Administer the medication with the needle at a 45-degree angle.
• B. Administer the medication with the needle at a 90-degree angle.
• C. Administer the medication with the needle at a 30-degree angle.
• D. Administer the medication with the needle at a 15-degree angle.

Correct answer: B

Rationale: Enoxaparin should be administered with the needle at a 90-degree angle to ensure proper subcutaneous delivery. Choice B is correct as it aligns with the recommended angle for subcutaneous injections. Administering enoxaparin at a 45-degree angle (Choice A), 30-degree angle (Choice C), or 15-degree angle (Choice D) would not be appropriate and may lead to improper administration or absorption of the medication.

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