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. The healthcare provider is caring for a client with a history of deep vein thrombosis (DVT). Which symptom would be most concerning?

• A. Pain in the affected leg
• B. Redness and warmth in the affected leg
• C. Shortness of breath
• D. Swelling in the affected leg

Correct answer: C

Rationale: Shortness of breath is the most concerning symptom in a client with a history of deep vein thrombosis (DVT) because it could indicate a pulmonary embolism. A pulmonary embolism is a serious complication of DVT where a blood clot travels to the lungs and can be life-threatening. Immediate medical attention is required to prevent further complications. Pain, redness, warmth, and swelling in the affected leg are common symptoms of DVT itself but do not pose the same level of immediate danger as the potential for a pulmonary embolism.

3. During a client admission, how should the nurse conduct medication reconciliation?

• A. Compare the client’s home medications to the provider's prescriptions.
• B. Review the client’s medical history.
• C. Assess the client's current medications.
• D. Ask the client about their allergies.

Correct answer: A

Rationale: During medication reconciliation, the nurse should compare the client’s home medications with the provider's prescriptions to ensure accuracy and prevent medication errors. Reviewing the client’s medical history (Choice B) is important but not the primary focus of medication reconciliation. Assessing the client's current medications (Choice C) is also vital but is not specific to the comparison between home and prescribed medications during reconciliation. Asking the client about their allergies (Choice D) is relevant for ensuring safe medication administration but is not the primary step in medication reconciliation, which involves comparing actual medications.

4. A nurse educator is conducting a parenting class for new guardians of infants. Which of the following statements made by a participant indicated understanding?

• A. “I will set my water heater at 130°F.”
• B. “Once my baby can sit up, they should be safe in the bathtub.”
• C. “I will place my baby on their stomach to sleep.”
• D. “Once my infant starts to push up, I will remove the mobile from over the crib.”

Correct answer: D

Rationale: The correct answer is D. Removing the mobile when the baby starts to push up prevents choking hazards as infants can reach and grab objects posing a risk of choking. Choice A is unsafe as setting the water heater at 130°F can scald a child. Choice B is incorrect because even when a baby can sit up, they still require close supervision in the bathtub. Choice C is unsafe as current guidelines recommend placing babies on their backs to sleep to reduce the risk of sudden infant death syndrome (SIDS). Therefore, choices A, B, and C are incorrect or unsafe practices for infant care.

5. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make?

• A. "It must be difficult to care for someone who is confined to bed."
• B. "It is important to keep the client clean to avoid infections."
• C. "I understand that this is challenging; let’s work together to ensure comfort."
• D. "The smell is quite strong; we need to address this immediately."

Correct answer: C

Rationale: The correct response is C: "I understand that this is challenging; let’s work together to ensure comfort." This response acknowledges the difficulty the partner is facing, shows empathy, and offers to collaborate in providing care. Choice A is incorrect because it does not directly address the partner's feelings of embarrassment or offer support. Choice B, while true, does not address the partner's emotional state and may come across as directive rather than supportive. Choice D is also incorrect as it focuses solely on the smell without addressing the partner's emotions or offering assistance in managing the situation with empathy.

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