Nursing Elites

1. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

• A. At home I take my pills at 8:00 am.
• B. It costs a lot of money to buy all of these pills.
• C. I get so tired of taking pills every day.
• D. This is a new pill I have never taken before.

Correct answer: D

Rationale: The client's statement that 'This is a new pill I have never taken before' indicates the need for further assessment by the nurse to ensure the medication is correct and safe. Choices A, B, and C do not raise immediate concerns about the medication order; therefore, they are incorrect. Choice A simply provides information about the client's usual medication schedule, choice B is related to the cost of the pills, and choice C expresses fatigue from taking pills, but none of these statements suggest a potential issue with the new medication.

2. In a client with moderate, persistent, chronic neuropathic pain due to diabetic neuropathy who takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily, if Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?

• A. Continue gabapentin.
• B. Discontinue ibuprofen.
• C. Add aspirin to the protocol.
• D. Add oral methadone to the protocol.

Correct answer: A

Rationale: In the presence of moderate, persistent, chronic neuropathic pain, the WHO pain relief ladder recommends continuing gabapentin, as it is effective for managing both anxiety and pain. Ibuprofen, a nonsteroidal anti-inflammatory drug, is not the mainstay for neuropathic pain relief according to the ladder and can be discontinued if needed. Aspirin is not typically added to the protocol for neuropathic pain management at this step. Methadone is reserved for severe pain and is not the standard choice at Step 2 of the WHO pain relief ladder for neuropathic pain.

3. A male healthcare provider is assigned to care for a female Muslim client. When the provider offers to bathe the client, the client requests that a female healthcare provider perform this task. How should the male healthcare provider respond?

• A. May I ask a female colleague to help you with your personal hygiene?
• B. I will ask one of the female healthcare providers to bathe you.
• C. A staff member on the next shift will help you.
• D. I will keep you draped and hand you the supplies as you need them.

Correct answer: B

Rationale: The most culturally sensitive response is for the male healthcare provider to ask one of the female healthcare providers to bathe the client. This approach respects the client's cultural and spiritual preferences by ensuring that their modesty and beliefs are honored during the care process. Choice A is incorrect as it puts the responsibility on the client to seek help, while the provider should take the initiative to arrange for appropriate care. Choice C is incorrect as it delays the assistance unnecessarily. Choice D, although helpful in maintaining modesty, does not address the client's request for a female healthcare provider to perform the task.

4. The client has a chest tube. What is the most important action for the nurse to take?

• A. Ensure the chest tube remains unclamped at all times.
• B. Empty the chest tube every 2 hours.
• C. Keep the drainage system below the level of the chest.
• D. Assess for subcutaneous emphysema.

Correct answer: C

Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.

5. The healthcare professional is administering an intermittent infusion of an antibiotic to a client with an antecubital saline lock. After opening the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should be taken first?

• A. Check for a blood return.
• B. Reposition the client's arm.
• C. Remove the IV site dressing.
• D. Flush the lock with saline.

Correct answer: B

Rationale: Repositioning the client's arm is the initial action to take when encountering an obstruction with an antecubital saline lock. Repositioning may correct any bending at the elbow that could be causing the obstruction, allowing for smoother infusion flow. Checking for a blood return, removing the IV site dressing, or flushing the lock with saline would be subsequent actions once the obstruction is addressed. Checking for a blood return is done to confirm proper placement, removing the IV site dressing is necessary for site assessment, and flushing the lock with saline helps maintain patency but should not be the first action when an obstruction is detected.

Similar Questions