Nursing Elites

1. How should a healthcare professional assess a patient's pain level post-surgery?

• A. Use a pain rating scale
• B. Check vital signs
• C. Observe for non-verbal cues
• D. Check for abnormal breath sounds

Correct answer: A

Rationale: Corrected Rationale: Using a pain rating scale is the most appropriate method to assess a patient's pain level post-surgery. Pain rating scales provide a standardized way for patients to communicate their pain intensity, allowing for accurate assessment and effective pain management. Checking vital signs (choice B) is important for monitoring a patient's overall health status but may not directly reflect their pain level. Observing for non-verbal cues (choice C) is valuable, but it may not always provide a clear indication of the pain intensity. Checking for abnormal breath sounds (choice D) is relevant for assessing respiratory status but does not directly evaluate the patient's pain level.

2. A client is experiencing a seizure. Which of the following interventions should the nurse implement?

• A. Place a tongue depressor in the client's mouth
• B. Loosen tight clothing around the client
• C. Restrain the client's arms and legs
• D. Administer 100% oxygen via non-rebreather mask

Correct answer: B

Rationale: During a seizure, it is essential to loosen tight clothing around the client to prevent injury and promote adequate ventilation. Placing any objects, like a tongue depressor, in the client's mouth can lead to airway obstruction or injury. Restraining the client's arms and legs can exacerbate the situation by increasing muscle rigidity and potentially causing injury. Administering oxygen via a non-rebreather mask is not typically indicated during a seizure unless respiratory distress is present.

3. A nurse is caring for a client who is 1 hour postoperative following a thoracentesis. Which of the following findings should the nurse report to the provider?

• A. Oxygen saturation of 96%
• B. Tracheal deviation
• C. Pain level of 4 on a scale of 0 to 10
• D. Temperature of 37.4°C (99.3°F)

Correct answer: B

Rationale: Tracheal deviation is the correct finding to report to the provider. It can indicate a pneumothorax, which is a serious complication following a thoracentesis that requires immediate attention. Oxygen saturation of 96% is within the normal range and does not indicate an immediate issue. A pain level of 4 on a scale of 0 to 10 is subjective and may not be related to a serious complication. A temperature of 37.4°C (99.3°F) is slightly elevated but not a priority over tracheal deviation in this context.

4. A nurse is reviewing the medical record of a client who has a history of myocardial infarction. Which of the following findings should the nurse report to the provider?

• A. Blood pressure 140/90 mm Hg
• B. Heart rate of 88/min
• C. LDL cholesterol 110 mg/dL
• D. Respiratory rate of 16/min

Correct answer: D

Rationale: In a client with a history of myocardial infarction, a respiratory rate of 16/min should be reported to the provider. Changes in respiratory rate can indicate cardiac or pulmonary issues that need further evaluation. The other vital signs provided (blood pressure, heart rate, and LDL cholesterol level) are within normal limits and do not directly relate to potential complications following a myocardial infarction.

5. A client who is receiving continuous enteral feedings through a nasogastric tube needs preventive measures to avoid aspiration. Which of the following actions should the nurse take?

• A. Elevate the head of the bed to 30 degrees.
• B. Check gastric residual volumes every 4 hours.
• C. Administer the feeding at room temperature.
• D. Flush the feeding tube with 20 mL of water every 8 hours.

Correct answer: B

Rationale: The correct answer is to check gastric residual volumes every 4 hours. This action helps prevent aspiration by ensuring the stomach is emptying properly, reducing the risk of reflux and aspiration. Elevating the head of the bed to 30 degrees can help prevent aspiration by promoting proper digestion and reducing the risk of regurgitation. Administering the feeding at room temperature is important for patient comfort but does not directly prevent aspiration. Flushing the feeding tube with water every 8 hours is important for tube patency but does not directly prevent aspiration.

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