Nursing Elites

1. The nurse is evaluating the effectiveness of guided imagery for pain management in a patient with second- and third-degree burns requiring extensive dressing changes. Which finding best indicates the effectiveness of guided imagery?

• A. The patient's need for analgesic medication decreases during the dressing changes.
• B. The patient rates pain during the dressing change as a 6 on a scale of 0 to 10.
• C. The patient asks for pain medication during the dressing changes only once throughout the procedure.
• D. The patient's facial expressions remain stoic during the procedure.

Correct answer: A

Rationale: The correct answer is A. A reduction in the need for analgesic medication indicates that guided imagery is effective in managing the patient's pain. Choices B, C, and D do not directly measure the effectiveness of guided imagery. A patient rating pain as 6 on a scale of 0 to 10, asking for pain medication once, or having stoic facial expressions may not necessarily reflect the impact of guided imagery on pain management.

2. The nurse is caring for a group of medical-surgical patients. A fire has been reported in an adjacent wing of the hospital. What should the nurse do to ensure the patients' safety?

• A. Wait until the fire department arrives before taking action.
• B. Close all doors.
• C. Identify evacuation routes.
• D. Move bedridden patients in their beds.

Correct answer: B

Rationale: During a fire emergency, it is crucial to close all doors to contain smoke and fire, helping to protect the patients. This action can prevent the spread of fire and smoke to the area where patients are located. Identifying evacuation routes is also important for a timely and orderly evacuation if necessary. Waiting for the fire department to arrive before taking action (Choice A) can waste valuable time and put patients at risk. Moving bedridden patients in their beds (Choice D) can be dangerous during a fire and should be avoided as it can expose patients and staff to more risks.

3. A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching?

• A. Increase dietary intake of raw vegetables
• B. Limit activity
• C. Drink four to five glasses of water daily
• D. Bear down hard when defecating

Correct answer: C

Rationale: The correct instruction the nurse should include is to advise the client to drink four to five glasses of water daily. Increasing water intake helps alleviate constipation by softening stool and increasing bowel movements. Choice A, increasing dietary intake of raw vegetables, can be helpful in preventing constipation but may not be sufficient as the sole intervention for someone already experiencing constipation. Choice B, limiting activity, can worsen constipation as physical activity helps stimulate bowel movements. Choice D, bearing down hard when defecating, can lead to other issues like hemorrhoids and should be avoided.

4. A nurse is preparing to discontinue a client's indwelling urinary catheter. Which of the following actions should the nurse take first?

• A. Measure and document the urine in the drainage bag
• B. Remove the tape or device securing the catheter to the client's thigh
• C. Position the client supine
• D. Deflate the catheter balloon using a sterile syringe

Correct answer: A

Rationale: The correct first action the nurse should take when discontinuing a client's indwelling urinary catheter is to measure and document the urine in the drainage bag. This step is essential to assess the client's urinary output and bladder function before removing the catheter. Removing the tape securing the catheter (Choice B) or positioning the client supine (Choice C) should come after measuring and documenting the urine output. Deflating the catheter balloon (Choice D) is the last step in the process of removing the catheter.

5. A nurse is evaluating a client receiving hemodialysis. Which of the following lab values requires immediate intervention?

• A. Sodium 135 mEq/L
• B. Potassium 6.5 mEq/L
• C. Calcium 9 mg/dL
• D. Chloride 98 mEq/L

Correct answer: B

Rationale: The correct answer is B. Potassium levels above 5.0 mEq/L can lead to cardiac issues, and a level of 6.5 mEq/L requires immediate intervention. Hyperkalemia can cause life-threatening cardiac arrhythmias. Choices A, C, and D are within normal ranges and do not require immediate intervention in the context of hemodialysis monitoring.

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