Nursing Elites

1. What should be included in the assessment of a client with a cast?

• A. capillary refill, warm toes, no discomfort.
• B. posterior tibial pulses, warm toes.
• C. moist skin essential, pain threshold.
• D. discomfort of the metacarpals.

Correct answer: A

Rationale: When assessing a client with a cast, it is crucial to check for capillary refill to ensure adequate circulation. Warm toes indicate good circulation, while the absence of discomfort suggests the cast is not causing any pain or undue pressure on the client. Therefore, choices B, C, and D are incorrect as they do not address the essential components of assessing a client with a cast.

2. A director of nursing at a long-term care center has announced a change to computerized documentation of nursing care. A certified nursing assistant (CNA) on the team, resistant to the change, is not taking an active part in facilitating the implementation of the new procedure. Which strategy would be the best approach to dealing with the conflict?

• A. Meeting with the CNA and encouraging him to express his feelings regarding the change
• B. Ignoring the resistance
• C. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs
• D. Telling the CNA that noncompliance will be documented in the personnel record

Correct answer: A

Rationale: The best approach to dealing with resistance to change is through open communication and understanding. Meeting with the CNA and encouraging him to express his feelings regarding the change allows for a constructive dialogue where issues can be addressed, and alternative solutions can be explored. Ignoring the resistance does not help in resolving the conflict and may lead to further issues. Telling the CNA that a licensed practical nurse (LPN) will perform all computer documentation while he documents intake and output and vital signs does not address the underlying concerns of the CNA and may create more resistance. Threatening the CNA with noncompliance consequences may escalate the resistance and create a negative work environment.

3. Priorities designated as intermediate by the nurse are:

• A. the nonemergency, non-life-threatening needs of the client.
• B. those tasks that can be delegated to assistive personnel.
• C. those tasks that can be performed at the end of the shift.
• D. those tasks that can be performed at any time

Correct answer: A

Rationale: Priorities designated as intermediate by the nurse are those that are not urgent but still important, such as the nonemergency, non-life-threatening needs of the client. They do not impact the client's immediate physiological status but require attention. Intermediate priorities may need the skill level of an RN for completion and may have specific time requirements. Choices B, C, and D are incorrect because the priority being intermediate doesn't mean it can be delegated, done at a specific time, or done at any time; it simply indicates a non-urgent but necessary task for the client's well-being.

4. When the nurse is determining the appropriate size of an oropharyngeal airway to insert, what part of a client's body should she measure?

• A. corner of the mouth to the tragus of the ear
• B. corner of the eye to the top of the ear
• C. tip of the chin to the sternum
• D. tip of the nose to the earlobe

Correct answer: B

Rationale: Correct! When sizing an oropharyngeal airway, the nurse should measure from the corner of the client's mouth to the tragus of the ear. This measurement ensures that the airway is the appropriate length to reach the pharynx without being too long or too short. Choices B, C, and D are incorrect as they do not provide the correct anatomical landmarks for determining the size of an oropharyngeal airway. Measuring from the corner of the mouth to the tragus of the ear is a standard method to ensure proper airway size and prevent complications during airway management.

5. Nonpharmacological pain management involves all of the following except:

• A. hypnosis alone.
• B. psychological care, including support groups.
• C. physical and psychological modalities.
• D. pain-reducing drugs only.

Correct answer: D

Rationale: Nonpharmacological pain management encompasses various strategies like hypnosis, psychological care, and physical and psychological modalities. The correct answer is 'pain-reducing drugs only' because nonpharmacological approaches do not solely rely on medications for pain management. Options A, B, and C are all valid components of nonpharmacological pain management. Hypnosis can help manage pain, psychological care including support groups can provide emotional support and coping strategies, and physical and psychological modalities encompass a wide range of interventions beyond just medication.

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