Nursing Elites

1. When evaluating the lab work of a client in hepatic coma, which of the following lab tests is most important?

• A. blood urea nitrogen
• B. serum calcium
• C. serum ammonia
• D. serum creatinine

Correct answer: C

Rationale: When a client is in hepatic coma due to liver failure, the liver cannot metabolize amino acids completely, leading to elevated ammonia levels. Increased ammonia can cause brain-tissue irritation, worsening the coma. Therefore, monitoring serum ammonia levels is crucial in assessing the severity of hepatic coma. Choices A, B, and D are less relevant in the context of hepatic coma. Blood urea nitrogen primarily assesses kidney function, serum calcium levels are not directly related to hepatic coma, and serum creatinine is more indicative of kidney function rather than liver function in this scenario.

2. All of the following tasks could be delegated to a nursing assistant or unlicensed assistive personnel (UAP) except:

• A. monitoring intravenous infusion
• B. assisting a client to the bathroom
• C. offering fluid intake every 1-2 hours
• D. monitoring/recording the amount of fluid taken

Correct answer: A

Rationale: Monitoring an intravenous infusion involves assessing for complications, adjusting the flow rate, and monitoring the client's response, which requires the knowledge and skills of a licensed nurse (RN or LPN). Tasks that can be delegated to nursing assistants or unlicensed assistive personnel include assisting a client to the bathroom, offering fluids, and recording fluid intake. These activities are within the scope of practice for UAPs as they do not involve the specialized knowledge and training needed for intravenous infusion monitoring.

3. When planning task assignments for five clients on the skilled nursing unit in a long-term care facility, which task should a licensed practical nurse (LPN) assign to another LPN?

• A. Bathing a client who is confused and requires assistance with a shower
• B. Administering regular insulin in accordance with a sliding-dosage scale every 4 hours to a client with diabetes mellitus
• C. Assisting a client requiring a bed bath and frequent ambulation with a cane
• D. Transporting a client who must be accompanied to physical therapy twice during the shift

Correct answer: B

Rationale: When assigning tasks, the nurse must consider the skills and educational level of the nursing staff. The nursing assistant may be assigned tasks like caring for a confused client, assisting with a shower or a bed bath, ambulating a client with a cane, and accompanying a client to physical therapy. The LPN is educated to administer medications like regular insulin in accordance with a sliding scale. This task requires a higher level of training and knowledge than the tasks that can be delegated to a nursing assistant. Administering insulin involves assessing blood glucose levels, calculating dosages, and understanding the effects of insulin therapy on the client's condition. Therefore, the correct answer is administering regular insulin to a client with diabetes mellitus. Choices A, C, and D involve tasks that are within the scope of practice of a nursing assistant, not an LPN.

4. When a client with a major burn experiences body image disturbance, which of the following is an appropriate nursing intervention classification?

• A. grief work facilitation
• B. vital signs monitoring
• C. medication administration: skin
• D. anxiety reduction

Correct answer: A

Rationale: The correct answer is 'grief work facilitation' because it is a nursing intervention classification specifically designed to address disturbed body image in burn clients. The expected outcome of this intervention is grief resolution, which can help the client cope with the body image changes resulting from the burn. Choice B, 'vital signs monitoring,' is not the appropriate intervention for body image disturbance in burn clients. Vital signs monitoring is typically used for assessing physiological parameters like blood pressure, pulse rate, and temperature. Choice C, 'medication administration: skin,' is more focused on treating skin-related issues rather than addressing body image disturbance. It involves the administration of medications to promote skin healing and integrity. Choice D, 'anxiety reduction,' is aimed at managing anxiety in clients with major burns and is not specifically targeted at addressing body image disturbance. While anxiety may be a common emotional response to burns, the most appropriate intervention for body image disturbance in this scenario is 'grief work facilitation.'

5. The client asks the nurse not to tell anyone outside of the care team about his positive HIV diagnosis. What response is most appropriate?

• A. "I have to inform all clients on the unit of your diagnosis as it is transmissible."?
• B. "I will not communicate your diagnosis to anyone without your permission."?
• C. "Because this is a communicable disease, it may need to be reported to the CDC."?
• D. "You should not be concerned with who I share your diagnosis with."?

Correct answer: C

Rationale: The most appropriate response is C: "Because this is a communicable disease, it may need to be reported to the CDC."? It is important to uphold patient confidentiality, but in the case of certain communicable diseases like HIV, there are legal requirements for mandatory reporting to public health authorities such as the CDC. Option A is incorrect because it violates patient confidentiality and does not consider legal obligations. Option B, while respecting the client's wishes, may not align with the legal requirement for reporting certain communicable diseases. Option D is inappropriate as it dismisses the client's concerns and rights regarding their health information.

Similar Questions