Nursing Elites

1. A nurse is discussing the care of a group of clients with a newly licensed nurse. Which of the following clients should the newly licensed nurse identify as experiencing chronic pain?

• A. A client who has a broken femur and reports hip pain.
• B. A client who has incisional pain 72 hours following pacemaker insertion.
• C. A client who has food poisoning and reports abdominal cramping.
• D. A client who has episodic back pain following a fall 2 years ago.

Correct answer: D

Rationale: Chronic pain is typically defined as pain lasting longer than 3-6 months or persisting after the expected time for tissue healing. Episodic back pain following a fall 2 years ago fits the criteria for chronic pain. Option A describes acute pain related to a recent fracture. Option B describes acute postoperative pain. Option C describes acute pain associated with an acute condition (food poisoning). Therefore, the correct identification of a client experiencing chronic pain is the one with episodic back pain from a past injury, as it has lasted beyond the normal healing time.

2. A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?

• A. Empty the drainage bag at least every 8 hours
• B. Keep the drainage bag below the level of the bladder
• C. Use sterile technique to collect a specimen from the drainage system
• D. Secure the catheter to the lower abdomen with a securement device

Correct answer: B

Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).

3. When planning to perform passive range-of-motion exercises for a client, what action should a healthcare professional take?

• A. Repeat each joint motion five times during each session.
• B. Perform the exercises quickly to save time.
• C. Focus only on the most affected joints.
• D. Assess the client's range of motion before starting.

Correct answer: A

Rationale: The correct answer is to repeat each joint motion five times during each session. Repetition is crucial to maintaining joint flexibility and muscle function. By ensuring each joint motion is repeated, the client can benefit fully from the passive range-of-motion exercises. Choice B is incorrect because quick performance may compromise technique and risk injury. Choice C is incorrect as neglecting less affected joints can lead to imbalances and hinder overall progress. Choice D is incorrect as assessing the client's range of motion beforehand is vital, but it is not the immediate action to take during the exercise session.

4. A client has been on bed rest for several weeks. Which finding should the nurse identify as the priority during assessment?

• A. Musculoskeletal weakness
• B. Loss of appetite
• C. Increased heart rate during physical activity
• D. Left lower extremity tenderness

Correct answer: D

Rationale: The nurse should prioritize assessing left lower extremity tenderness as it could indicate deep vein thrombosis, a serious condition that requires immediate attention. Musculoskeletal weakness, loss of appetite, and increased heart rate during physical activity are important but not as critical as a potential thrombotic event that could lead to life-threatening complications. Deep vein thrombosis is a common risk for individuals on prolonged bed rest due to reduced mobility and blood stasis.

5. In a disaster at a child day care center, which child would the triage nurse prioritize for treatment last?

• A. An infant with intermittent bulging anterior fontanel between crying episodes
• B. A toddler with severe deep abrasions covering 98% of the body
• C. A preschooler with a lower leg fracture and an upper leg fracture on the other leg
• D. A school-age child with singed eyebrows and hair on the arms

Correct answer: B

Rationale: The toddler with severe deep abrasions covering 98% of the body would be prioritized for treatment last because these extensive injuries may require immediate attention and resources. The other choices present serious conditions but are not as severe or life-threatening as the toddler's injuries. The infant with an intermittent bulging anterior fontanel may have signs of increased intracranial pressure, requiring prompt evaluation. The preschooler's fractures, though serious, can be managed without immediate critical intervention. The school-age child with singed eyebrows and hair may have suffered burns but does not exhibit injuries as severe as the toddler's deep abrasions.

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