Nursing Elites

1. By the second postoperative day, a client has not achieved satisfactory pain relief. Based on this evaluation, which of the following actions should the nurse take, according to the nursing process?

• A. Reassess the client to determine the reasons for inadequate pain relief.
• B. Wait to see whether the pain lessens during the next 24 hours.
• C. Change the plan of care to provide different pain relief interventions.
• D. Teach the client about the plan of care for managing pain.

Correct answer: A

Rationale: Reassessing the client is crucial to identify the reasons for inadequate pain relief. This action allows the nurse to gather more information, evaluate the current pain management interventions, and make necessary adjustments to the care plan. Waiting for the pain to lessen without taking action delays appropriate pain management. Changing the plan of care without reassessment may lead to ineffective interventions. Teaching the client about the plan of care should be based on a reassessment of the current pain relief status to ensure tailored and effective pain management strategies.

2. A healthcare professional is preparing to administer an intramuscular injection to a client. Which site is most appropriate for the healthcare professional to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Dorsogluteal site
• D. Rectus femoris site

Correct answer: B

Rationale: The ventrogluteal site is the most appropriate site for administering an intramuscular injection to an adult client. This site is preferred due to its large muscle mass and distance from major nerves and blood vessels, reducing the risk of injury or complications. The deltoid muscle, while commonly used for vaccinations, may not be suitable for certain medications due to its smaller muscle mass. The dorsogluteal site is no longer recommended due to the proximity of the sciatic nerve, which can lead to complications. The rectus femoris site is not commonly used for intramuscular injections in clinical practice.

3. During an eye irrigation for a client exposed to smoke and ash, which nursing action should receive the highest priority?

• A. Wearing gloves during the procedure
• B. Using a sterile solution
• C. Irrigating from the inner to the outer canthus
• D. Positioning the client's head properly

Correct answer: A

Rationale: The highest priority during an eye irrigation for a client exposed to smoke and ash is wearing gloves during the procedure. This action is crucial as it helps prevent contamination and protects both the client and the nurse. Using a sterile solution is important but not as critical as ensuring the nurse's safety by wearing gloves. Irrigating from the inner to the outer canthus and positioning the client's head properly are essential steps in eye irrigation, but they are not the highest priority in this scenario compared to ensuring infection control by wearing gloves.

4. When measuring a client's blood pressure, which approach is the priority for a nurse caring for a client with hypertension?

• A. Obtain the blood pressure under the same conditions each time
• B. Use a different arm for each measurement
• C. Measure the blood pressure while the client is standing
• D. Take multiple readings at different times of the day

Correct answer: A

Rationale: The correct approach when measuring a client's blood pressure, especially for a client with hypertension, is to obtain the blood pressure under the same conditions each time. Consistency in measurement conditions helps ensure accurate and comparable blood pressure readings. Using a different arm for each measurement (Choice B) is not ideal as it can lead to variations in readings. Measuring the blood pressure while the client is standing (Choice C) is not the standard practice and may not provide accurate results. Taking multiple readings at different times of the day (Choice D) may be useful for monitoring blood pressure trends but is not the priority when ensuring accurate individual readings.

5. A client admitted with sudden onset of severe back pain of unknown origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain?

• A. Tell me how you are feeling right now.
• B. Describe the pain you are experiencing.
• C. Can you tell me more about your back pain?
• D. When did the pain start and how severe is it?

Correct answer: B

Rationale: The correct answer is B: 'Describe the pain you are experiencing.' This question is the most effective as it prompts the client to provide detailed information about the nature of the pain, including its characteristics, intensity, and location. This detailed description can help the nurse in assessing the possible cause and severity of the pain. Choices A, C, and D are not as effective as they are either too general ('Tell me how you are feeling right now'), redundant ('Can you tell me more about your back pain?'), or focused only on timing and severity ('When did the pain start and how severe is it?').

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