Nursing Elites

1. A charge nurse is making staff assignments on a medical-surgical unit. Which of the following tasks should the nurse plan to delegate to an assistive personnel?

• A. Measuring oxygen saturation for a client who has dyspnea
• B. Inserting a rectal suppository for a client who is vomiting
• C. Performing nasal hygiene for a client who has an NG tube
• D. Pouching a client's ostomy bag for a new colostomy

Correct answer: D

Rationale: Pouching a new colostomy is a task that can be safely and appropriately delegated to an assistive personnel as it falls within their scope of practice. Measuring oxygen saturation (Choice A) requires a higher level of training and assessment, making it unsuitable for delegation. Inserting a rectal suppository (Choice B) and performing nasal hygiene (Choice C) involve invasive procedures that are typically performed by licensed nursing staff due to the associated risks and complexities, making them inappropriate for delegation to assistive personnel.

2. A nurse is caring for a client who is unconscious and whose partner is their health care surrogate. The partner wishes to discontinue the client's feeding tube, but another family member tells the nurse that they want the client to continue receiving treatment. Which of the following responses should the nurse make?

• A. You should contact the provider about your wishes for your family member.
• B. We'll need to have the nursing supervisor review the client's advance directives.
• C. You should speak with the facility's ethics committee about your concerns.
• D. As the health care surrogate, the client's partner can make this decision.

Correct answer: D

Rationale: The correct response is D because the health care surrogate, as designated by the client, has the legal authority to make healthcare decisions on behalf of the client when they are unable to do so. This authority includes decisions about treatment continuation or withdrawal. Option A is incorrect as the family member's wishes do not override the legal authority of the health care surrogate. Option B is not the most appropriate action in this situation as the advance directives are already clear by the designation of a health care surrogate. Option C is not necessary at this stage since the health care surrogate can make the decision without involving the ethics committee.

3. Rotating injection sites when administering insulin prevents which of the following complications?

• A. Insulin edema
• B. Insulin lipodystrophy
• C. Insulin resistance
• D. Systemic allergic reactions

Correct answer: B

Rationale: Rotating injection sites when administering insulin helps prevent insulin lipodystrophy, which is the abnormal distribution of fat at injection sites. Insulin edema (choice A) is not prevented by rotating injection sites; it is characterized by swelling at the site of insulin injection due to increased capillary permeability. Insulin resistance (choice C) is a condition where the body's cells become less responsive to insulin, and rotating injection sites does not directly prevent this. Systemic allergic reactions (choice D) are not specifically prevented by rotating injection sites; they are related to an allergic response to insulin.

4. What does the mnemonic device ABCDE stand for?

• A. Allergy, bleeding, chemicals, dietary, environment
• B. Allergy, bleeding, cardio, diabetes, endocrine
• C. Allergy, bleeding, cardio, digestive, endocrine
• D. Allergy, bleeding, cortisone, diabetes, emboli

Correct answer: D

Rationale: The correct answer is D: 'Allergy, bleeding, cortisone, diabetes, emboli.' The ABCDE mnemonic is used in healthcare to help remember key assessment points. Choice A is incorrect as 'chemicals' and 'dietary' are not part of the ABCDE assessment. Choice B is incorrect as 'cardio' is not part of the ABCDE mnemonic. Choice C is incorrect as 'cardio' and 'digestive' are not part of the ABCDE mnemonic.

5. Which nonpharmacological technique involves the use of electronic monitoring equipment while the patient controls basic bodily mechanisms?

• A. Meditation
• B. Visualization
• C. Biofeedback
• D. Chiropractic

Correct answer: C

Rationale: The correct answer is C: Biofeedback. Biofeedback is a nonpharmacological technique that uses electronic monitoring equipment to provide real-time data on physiological processes such as heart rate, muscle tension, and skin temperature. Through this feedback, patients learn to control and regulate these bodily functions voluntarily. Choice A, Meditation, involves focusing the mind and reducing stress through techniques like mindfulness or deep breathing, but it does not specifically rely on electronic monitoring equipment. Choice B, Visualization, is a technique where individuals imagine peaceful scenes to promote relaxation and reduce anxiety, and it also does not involve electronic monitoring. Choice D, Chiropractic, is a healthcare profession that focuses on the diagnosis and treatment of musculoskeletal disorders through manual adjustments and manipulation, which is unrelated to the use of electronic monitoring equipment for controlling bodily functions.

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