Nursing Elites

1. To assess the quality of an adult client’s pain, what approach should the nurse use?

• A. Ask the client to rate the pain on a scale of 1 to 10.
• B. Ask the client to describe the pain.
• C. Observe the client’s nonverbal cues.
• D. Determine the client’s pain tolerance.

Correct answer: B

Rationale: The correct approach for assessing the quality of an adult client's pain is to ask the client to describe the pain. By doing so, the nurse gains valuable information about the quality, location, and nature of the pain directly from the client. This approach allows for a more comprehensive understanding of the pain experience. Choice A, asking the client to rate the pain on a scale of 1 to 10, focuses more on intensity rather than quality. Choice C, observing the client's nonverbal cues, can provide additional information but may not fully capture the client's subjective experience of pain. Choice D, determining the client's pain tolerance, is not directly related to assessing the quality of pain but rather to how much pain a client can endure.

2. The nurse is caring for a client with myasthenia gravis. Which symptom is most important for the nurse to report to the healthcare provider?

• A. Diplopia (double vision)
• B. Difficulty swallowing
• C. Weakness in the legs
• D. Fatigue

Correct answer: B

Rationale: In a client with myasthenia gravis, difficulty swallowing is the most crucial symptom to report to the healthcare provider. This is because it can lead to aspiration, a severe complication in these clients. Diplopia (double vision) and weakness in the legs are common symptoms of myasthenia gravis but are not as immediately dangerous as difficulty swallowing. Fatigue is also a common symptom in myasthenia gravis but does not pose the same risk of aspiration as difficulty swallowing.

3. After a CT scan with intravenous contrast medium, a client returns to the room complaining of shortness of breath and itching. Which intervention should the nurse implement?

• A. Call respiratory therapy to administer a breathing treatment.
• B. Send for an emergency tracheostomy set.
• C. Prepare a dose of epinephrine.
• D. Review the client's complete list of allergies.

Correct answer: C

Rationale: Preparing a dose of epinephrine is the correct intervention in this situation as the client is displaying symptoms of an anaphylactic reaction to the contrast medium used during the CT scan. Epinephrine is the first-line treatment for anaphylaxis due to its ability to reverse the symptoms rapidly. Calling respiratory therapy for a breathing treatment (Choice A) may not address the underlying allergic reaction and delay appropriate treatment. Sending for an emergency tracheostomy set (Choice B) is not indicated as the client's symptoms suggest an allergic reaction rather than airway obstruction. Reviewing the client's complete list of allergies (Choice D) is important but would not provide immediate relief for the client's current symptoms; administering epinephrine takes precedence in this situation.

4. The healthcare provider is assessing a client with a chest tube. Which finding indicates that the chest tube is functioning properly?

• A. Continuous bubbling in the water seal chamber
• B. Tidaling in the water seal chamber
• C. Absence of drainage in the collection chamber
• D. Fluid level in the suction control chamber is below the prescribed level

Correct answer: B

Rationale: Tidaling in the water seal chamber indicates proper chest tube function. Tidaling refers to the rise and fall of fluid in the water seal with inhalation and exhalation, demonstrating the patency of the system. Continuous bubbling (Choice A) in the water seal chamber indicates an air leak. Absence of drainage in the collection chamber (Choice C) is not a desired finding as it suggests no drainage is occurring. A fluid level below the prescribed level in the suction control chamber (Choice D) may indicate inadequate suction.

5. The nurse is caring for a client with a suspected stroke. Which assessment finding is most indicative of a stroke?

• A. Chest pain
• B. Sudden confusion and difficulty speaking
• C. Gradual onset of weakness in the legs
• D. Nausea and vomiting

Correct answer: B

Rationale: The correct answer is B: Sudden confusion and difficulty speaking. These are classic signs of a stroke, indicating a neurological deficit that requires urgent medical attention. Choices A, C, and D are less indicative of a stroke. Chest pain is more commonly associated with cardiac issues, gradual onset of weakness in the legs could be related to other conditions like peripheral neuropathy, and nausea/vomiting may suggest gastrointestinal problems rather than a stroke.

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