Nursing Elites

1. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

• A. Giving a glycerin suppository to a client for constipation
• B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache
• C. Discussing dietary changes with a client who has a prescription for a gluten-free diet
• D. Measuring hourly urinary output for a client who is postoperative

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

2. How should a healthcare professional respond to a patient experiencing hypoglycemia?

• A. Rechecking the blood glucose level in 15 minutes
• B. Encouraging the patient to eat a high-protein snack
• C. Administering 15g of fast-acting carbohydrates
• D. Administering glucagon if the patient is unconscious

Correct answer: C

Rationale: The correct response to a patient experiencing hypoglycemia is to administer 15g of fast-acting carbohydrates. This helps quickly increase the blood glucose levels in the patient, addressing the low blood sugar. Rechecking the blood glucose level in 15 minutes (Choice A) may delay necessary intervention, encouraging a high-protein snack (Choice B) is not recommended as it does not rapidly increase blood sugar levels, and administering glucagon if the patient is unconscious (Choice D) is typically done in severe cases of hypoglycemia when the patient is unable to eat or drink.

3. A patient is admitted and is placed on fall precautions. The nurse teaches the patient and family about fall precautions. Which action will the nurse take in accordance with hospital policy?

• A. Encourage visitors during visiting hours.
• B. Keep the patient on fall precautions until discharge.
• C. Check on the patient every shift.
• D. Raise all four side rails.

Correct answer: B

Rationale: The correct answer is B because patients on fall precautions need continuous monitoring until discharge to prevent falls. While encouraging visitors during visiting hours (Choice A) is important for the patient's well-being, it is not related to fall precautions. Checking on the patient every shift (Choice C) is an essential nursing intervention, but keeping the patient on fall precautions is more specific to preventing falls. Raising all four side rails (Choice D) is not recommended as it can restrict the patient's mobility and is considered a restraint practice.

4. A nurse is assessing a client who is being admitted from the PACU following an abdominal hysterectomy. Which of the following assessments is the nurse's priority?

• A. Urinary output
• B. Pain level
• C. Oxygen saturation
• D. Abdominal dressing

Correct answer: C

Rationale: The correct answer is C: Oxygen saturation. Following abdominal surgery, the priority assessment is to ensure adequate oxygenation. Monitoring oxygen saturation is crucial as the client may be at risk of respiratory complications due to the effects of anesthesia, pain medications, and the surgical procedure itself. Assessing urinary output is important for monitoring kidney function but is not the priority immediately postoperatively. Pain level assessment is essential for the client's comfort but does not take precedence over ensuring oxygen saturation. Checking the abdominal dressing is important for wound assessment, but ensuring adequate oxygenation is the priority in the immediate postoperative period.

5. A patient reports nausea and vomiting after chemotherapy. What is the nurse's priority action?

• A. Administer an antiemetic as prescribed.
• B. Encourage the patient to eat small, frequent meals.
• C. Provide the patient with anti-nausea wristbands.
• D. Encourage the patient to rest after eating.

Correct answer: A

Rationale: The correct answer is to administer an antiemetic as prescribed. Chemotherapy-induced nausea and vomiting can be distressing for patients. Administering an antiemetic helps alleviate these symptoms effectively. Choice B, encouraging the patient to eat small, frequent meals, may be helpful for other gastrointestinal issues but is not the priority when the patient is experiencing nausea and vomiting. Choice C, providing anti-nausea wristbands, may offer some relief but is not as direct and immediate as administering an antiemetic. Choice D, encouraging the patient to rest after eating, is not the priority in this situation where the focus should be on managing the nausea and vomiting.

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