Nursing Elites

1. A charge nurse is teaching a group of nurses about delegation. Which task should the nurse delegate to assistive personnel (AP)?

• A. Teaching a new mother how to breastfeed.
• B. Assisting a client with ambulation post-surgery.
• C. Helping with medication administration.
• D. Delegating IV medication administration.

Correct answer: B

Rationale: The correct answer is B. Assisting a client with ambulation post-surgery is a task that can be appropriately delegated to assistive personnel (AP) as it falls within their scope of duties. Teaching a new mother how to breastfeed and helping with medication administration involve assessments and critical thinking that are typically within the scope of licensed nursing staff, not AP. Delegating IV medication administration involves a higher level of skill and knowledge that should be performed by licensed nursing staff.

2. A nurse realizes that the wrong medication has been administered to a client. Which of the following actions should the nurse take first?

• A. Notify the provider
• B. Report the incident to the nurse manager
• C. Monitor vital signs
• D. Fill out an incident report

Correct answer: C

Rationale: The correct first action for the nurse to take after realizing that the wrong medication has been administered to a client is to monitor vital signs. Monitoring vital signs is crucial as it allows the nurse to promptly assess for any immediate adverse effects that may result from the wrong medication. This immediate assessment is essential for ensuring the client's safety and well-being. Notifying the provider (choice A) and reporting the incident to the nurse manager (choice B) are important steps to take, but they should come after ensuring the client's immediate safety. Filling out an incident report (choice D) is also necessary but should be done after addressing the client's immediate needs.

3. A client is being assessed in the PACU. Which of the following findings indicates decreased cardiac output?

• A. Shivering
• B. Oliguria
• C. Bradypnea
• D. Constricted pupils

Correct answer: B

Rationale: Oliguria is a sign of decreased cardiac output. Decreased cardiac output can lead to poor renal perfusion, resulting in decreased urine output (oliguria). This requires immediate intervention to improve cardiac function and perfusion. Shivering (Choice A) is a response to cold stress and does not directly indicate decreased cardiac output. Bradypnea (Choice C) refers to abnormally slow breathing rate and is more indicative of respiratory issues rather than decreased cardiac output. Constricted pupils (Choice D) are associated with the parasympathetic nervous system response and not directly related to cardiac output.

4. How should a healthcare professional manage a patient with respiratory distress?

• A. Administer bronchodilators
• B. Administer oxygen
• C. Check oxygen saturation
• D. Reposition the patient

Correct answer: B

Rationale: Administering oxygen is crucial in managing a patient with respiratory distress as it helps improve oxygenation and alleviate breathing difficulties. While administering bronchodilators may be beneficial in certain respiratory conditions like asthma or COPD, in a patient with respiratory distress, ensuring adequate oxygen supply takes precedence. Checking oxygen saturation is important, but the immediate intervention to address respiratory distress is providing supplemental oxygen. Repositioning the patient may be helpful in optimizing ventilation but is not the primary intervention in managing acute respiratory distress.

5. A nurse is caring for a client with schizophrenia. Which of the following assessment findings should the nurse expect?

• A. Decreased level of consciousness
• B. Inability to identify common objects
• C. Poor problem-solving ability
• D. Preoccupation with somatic disturbances

Correct answer: B

Rationale: In schizophrenia, clients often display an inability to identify common objects due to cognitive impairment. This is known as associative agnosia, where individuals struggle to recognize familiar objects, faces, or sounds. Choices A, C, and D are not typically associated with schizophrenia. Decreased level of consciousness is more indicative of conditions like head trauma or drug overdose. Poor problem-solving ability may be seen in various mental health disorders but is not specific to schizophrenia. Preoccupation with somatic disturbances is more commonly seen in somatic symptom disorders or somatic delusions, not a typical finding in schizophrenia.

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