Nursing Elites

1. A nurse prepares to admit a client who is immediately postoperative to the unit following abdominal surgery. When transferring the client from the gurney to the bed, what should the nurse do?

• A. Lock the wheels on the bed and gurney
• B. Adjust the bed height
• C. Use a slide sheet
• D. Ask for assistance from another nurse

Correct answer: A

Rationale: The correct action for the nurse to take when transferring a postoperative client from the gurney to the bed is to lock the wheels on both the bed and the gurney. Locking the wheels ensures stability and prevents accidents during the transfer. Adjusting the bed height may be necessary for comfort but is not the primary concern during the transfer process. Using a slide sheet may be helpful in repositioning the client once on the bed but is not essential for the initial transfer. Asking for assistance from another nurse is always a good practice, but the immediate action to ensure safety during the transfer is to lock the wheels.

2. The nurse is providing discharge teaching to a client who has a new prescription for digoxin (Lanoxin). Which statement by the client indicates a need for further teaching?

• A. I will take my pulse before taking the medication.
• B. I will take the medication at the same time every day.
• C. I should avoid taking antacids at the same time as this medication.
• D. I should eat foods high in potassium while taking this medication.

Correct answer: D

Rationale: The correct answer is D. Clients taking digoxin should avoid eating foods high in potassium, as this can affect the medication's efficacy. Choices A, B, and C are correct statements regarding digoxin administration and precautions, indicating the client's understanding of the medication and its management.

3. When admitting an older adult client who is Hispanic, which of the following cultural considerations should the nurse include when developing the plan of care?

• A. The Hispanic culture views late adulthood as a time of wisdom and experience
• B. The Hispanic culture expects adult children to care for older adult parents
• C. The Hispanic culture identifies the eldest female family member as the decision maker
• D. The Hispanic culture expects individuals to make their own decisions when death is imminent

Correct answer: B

Rationale: In Hispanic culture, there is an expectation that adult children will care for their older parents, emphasizing a strong family support system. This cultural value highlights the importance of filial piety and respect for elders within the family structure. Choice A is incorrect because Hispanic culture generally values late adulthood as a time of wisdom and experience, not a negative time. Choice C is incorrect as Hispanic culture typically involves collective family decision-making rather than assigning decision-making solely to the eldest female member. Choice D is incorrect as Hispanic culture values family support and involvement in end-of-life decisions rather than individual decision-making.

4. A nurse is collecting data from a client who is reporting pain despite taking analgesics. Which of the following actions should the nurse take to determine the intensity of the client’s pain?

• A. Ask the client what precipitates the pain.
• B. Question the client about the location of the pain.
• C. Offer the client a pain scale to measure their pain.
• D. Use open-ended questions to identify the client’s pain sensations.

Correct answer: C

Rationale: Offering the client a pain scale is the most appropriate action to determine the intensity of the client’s pain. Pain scales help quantify the intensity of pain, providing a standardized way to assess and compare pain levels. Asking about precipitating factors (choice A) may help identify triggers but does not directly measure pain intensity. Questioning about the location of pain (choice B) helps with localization but not with quantifying intensity. Using open-ended questions (choice D) may provide insights into the quality and experience of pain but does not provide a standardized measure of intensity.

5. While documenting in a client’s medical record, which of the following entries should the nurse record?

• A. “Incision without redness or drainage”
• B. “Drank adequate amounts of fluid with meals”
• C. “Administered pain medication”
• D. “Oral temperature slightly elevated at 0800”

Correct answer: D

Rationale: The correct answer is D because documenting specific observations, such as an oral temperature being slightly elevated at a specific time, is crucial for monitoring the client's health status accurately. This type of information helps in assessing trends and changes in the client's condition over time. Choice A is incorrect as it lacks specificity and does not provide measurable data about the client's condition. Choice B is incorrect because it is a general statement related to client behavior rather than a specific health observation. Choice C is incorrect as it reflects an action taken by the nurse and not a direct client's condition or observation.

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