Nursing Elites

1. What is the most appropriate method for assessing a patient's pain level?

• A. Observe the patient's facial expressions.
• B. Use a standardized pain scale, such as 0-10.
• C. Ask the patient to rate their pain based on their mood.
• D. Ask the patient's family members to assess the pain.

Correct answer: B

Rationale: The most appropriate method for assessing a patient's pain level is to use a standardized pain scale, such as a 0-10 scale. This method provides an objective and consistent way to measure and communicate the intensity of pain experienced by the patient. Choice A, observing facial expressions, can be subjective and may not always accurately reflect the level of pain. Choice C, asking the patient to rate their pain based on their mood, may be influenced by various factors unrelated to pain. Choice D, involving the patient's family members in assessing the pain, is not ideal as pain is a subjective experience that should be reported by the patient themselves.

2. A healthcare provider is reviewing the laboratory report of a client who is receiving heparin therapy for a deep vein thrombosis. Which of the following lab values indicates a therapeutic response to the therapy?

• A. PT of 12 seconds
• B. aPTT of 70 seconds
• C. Platelets of 150,000/mm3
• D. INR of 1.5

Correct answer: B

Rationale: An aPTT of 70 seconds is within the therapeutic range for a client receiving heparin therapy. The activated partial thromboplastin time (aPTT) is the most sensitive test to monitor heparin therapy. A therapeutic aPTT range for a client receiving heparin is usually 1.5 to 2.5 times the control value. Choices A, C, and D are not indicators of a therapeutic response to heparin therapy. PT measures the extrinsic pathway of coagulation and is not specific to monitoring heparin therapy. Platelet count is important to monitor for heparin-induced thrombocytopenia, but it does not indicate the therapeutic response to heparin therapy. INR is used to monitor warfarin therapy, not heparin therapy.

3. A nurse is assessing a client who has heart failure and is taking digoxin. The nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider?

• A. Diarrhea
• B. Vomiting
• C. Ringing in ears
• D. Dizziness

Correct answer: B

Rationale: The correct answer is B: Vomiting. Vomiting is a common sign of digoxin toxicity and should be reported to the healthcare provider. Diarrhea (Choice A) is a more common side effect of digoxin but not typically associated with toxicity. Ringing in the ears (Choice C) is a potential sign of toxicity; however, vomiting is a more immediate concern. Dizziness (Choice D) can occur with digoxin use but is not a specific indicator of toxicity.

4. A client has a new prescription for beclomethasone inhaler to use with an albuterol inhaler for asthma maintenance. What should the nurse instruct the client?

• A. Skip doses if breathing improves
• B. Use the albuterol inhaler first
• C. Gargle with water after each use
• D. Store inhaler in the refrigerator

Correct answer: C

Rationale: The correct answer is to instruct the client to gargle with water after each use of the beclomethasone inhaler. Beclomethasone can cause oral thrush, and gargling with water helps prevent this complication. Choice A is incorrect because the client should not skip doses even if breathing improves, as the medications are prescribed for maintenance. Choice B is incorrect as there is no specific instruction to use the albuterol inhaler first in this scenario. Choice D is incorrect because inhalers should not be stored in the refrigerator unless specified by the manufacturer.

5. A nurse is preparing a client for surgery. Which of the following actions should be taken first?

• A. Ensure informed consent is signed
• B. Start IV fluids
• C. Administer preoperative antibiotics
• D. Reinforce surgical site dressing

Correct answer: A

Rationale: The correct answer is to ensure informed consent is signed first when preparing a client for surgery. This step is crucial as it ensures that the client has been informed about the procedure, risks, benefits, and alternatives before giving consent. Starting IV fluids (choice B) may be necessary but comes after obtaining informed consent. Administering preoperative antibiotics (choice C) is important but typically follows confirming informed consent. Reinforcing surgical site dressing (choice D) is a postoperative step and does not take precedence over obtaining informed consent.

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