Nursing Elites

1. The nurse is caring for a patient who has a right-sided chest tube after a right lower lobectomy. Which nursing action can the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Document the amount of drainage every eight hours
• B. Obtain samples of drainage for culture from the system
• C. Assess patient pain level associated with the chest tube
• D. Check the water-seal chamber for the correct fluid level

Correct answer: A

Rationale: The correct answer is to document the amount of drainage every eight hours. UAP education typically includes tasks related to documentation of intake and output. Obtaining samples of drainage for culture and assessing patient pain level are nursing responsibilities that require licensed nursing personnel's education and scope of practice. Checking the water-seal chamber for the correct fluid level also falls under the nursing role, as it involves monitoring and maintaining the chest tube system, which requires nursing knowledge and training.

2. The healthcare provider is examining a patient who is reporting "feeling cold."? Which is a mechanism of heat loss in the body?

• A. Exercise
• B. Radiation
• C. Metabolism
• D. Food digestion

Correct answer: B

Rationale: When the body needs to lose heat, one of the mechanisms it employs is radiation. Radiation involves the transfer of heat from the body to the environment in the form of infrared waves. While metabolism, exercise, and food digestion contribute to heat production, they are not mechanisms for heat loss. Metabolism generates heat as a byproduct, exercise increases metabolic rate leading to heat production, and food digestion involves some heat generation, but these processes do not directly facilitate heat loss. Therefore, in the scenario where the patient is feeling cold, radiation is the primary mechanism for the body to lose excess heat and maintain a stable internal temperature.

3. A client in a long-term care facility has developed reddened skin over the sacrum, which has cracked and started to blister. The nurse confirms that the client has not been assisted with turning while in bed. Which stage of pressure ulcer is this client exhibiting?

• A. Stage I
• B. Stage II
• C. Stage III
• D. Stage IV

Correct answer: B

Rationale: The client is exhibiting a stage II pressure ulcer. A stage II pressure ulcer develops as a partial thickness wound that affects both the epidermis and the dermal layers of skin. This stage can present with red skin, blisters, or cracking, appearing shallow and moist. However, the ulcer does not extend to the underlying tissues at this stage. Choice A (Stage I) is incorrect as Stage I ulcers involve non-blanchable redness of intact skin. Choices C (Stage III) and D (Stage IV) are incorrect as they involve more severe tissue damage, extending into deeper layers of the skin and underlying tissues, which is not the case in this scenario.

4. The abbreviation pc is defined as ________________.

• A. before the meal
• B. with the meal
• C. after the meal
• D. post corpi

Correct answer: C

Rationale: The correct answer is C: 'after the meal.' In medical terminology, 'pc' is an abbreviation for 'post cibum,' which means 'after eating' or 'after the meal.' This term is used to indicate when a medication should be taken concerning meals. Choices A, B, and D are incorrect. 'Before the meal' (A) is typically abbreviated as 'ac,' 'with the meal' (B) is abbreviated as 'pc,' and 'post corpi' (D) is not a valid medical abbreviation or term.

5. The acronym FAST is used to help responders remember the steps to recognizing which of the following conditions?

• A. Onset of labor in a pregnant woman
• B. Stroke
• C. Heart attack
• D. Migraine

Correct answer: B

Rationale: The correct answer is B: Stroke. The acronym FAST is used to help recognize the signs of a stroke. The letters stand for Face, Arms, Speech, and Time. This mnemonic helps in identifying facial drooping, arm weakness, speech difficulties, and the importance of time in seeking emergency care. Choices A, C, and D are incorrect because the FAST acronym specifically pertains to stroke recognition, not the onset of labor, heart attacks, or migraines.

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