Nursing Elites

1. A client has a nasogastric tube after colon surgery. Which one of these tasks can be safely delegated to an unlicensed assistive personnel (UAP)?

• A. To observe the type and amount of nasogastric tube drainage
• B. Monitor the client for nausea or other complications
• C. Irrigate the nasogastric tube with the ordered irrigation solution
• D. Perform nostril and mouth care

Correct answer: D

Rationale: Performing nostril and mouth care is a non-invasive task that can be safely delegated to an unlicensed assistive personnel (UAP). Observing the type and amount of nasogastric tube drainage requires assessment skills and understanding of potential complications, making it more appropriate for a licensed healthcare professional. Monitoring the client for nausea or other complications involves interpreting client responses and identifying adverse reactions, which also requires a licensed healthcare professional. Irrigating the nasogastric tube with the ordered solution involves a procedure that can impact the client's condition and should be performed by a licensed healthcare professional to prevent complications.

2. Which documentation indicates that activities to prevent postoperative venous stasis were performed correctly?

• A. Antiembolism stockings on, leg exercises performed hourly.
• B. Antiembolism stockings removed hourly during leg exercises.
• C. Leg exercises not performed due to antiembolism hose.
• D. Client demonstrates ability to move extremities well.

Correct answer: A

Rationale: The correct answer is A: 'Antiembolism stockings on, leg exercises performed hourly.' This documentation indicates the correct performance of activities to prevent postoperative venous stasis, as both components are crucial for prevention. Choice B is incorrect because removing stockings hourly is not recommended. Choice C is incorrect as leg exercises should be performed despite wearing antiembolism stockings. Choice D is incorrect as demonstrating the ability to move extremities well does not specifically address the prevention of venous stasis.

3. The nurse is planning to administer two medications at 0900. Which property of the drugs indicates a need to monitor the client for toxicity?

• A. Short half-life
• B. High therapeutic index
• C. Highly protein-bound
• D. Low bioavailability

Correct answer: C

Rationale: The correct answer is C, 'Highly protein-bound.' Drugs that are highly protein-bound can displace from protein-binding sites, leading to increased free drug levels in the blood, which can result in toxicity. Monitoring the client for toxicity is crucial when administering highly protein-bound drugs. Choices A, B, and D are incorrect. A short half-life does not necessarily indicate a need for monitoring toxicity; a high therapeutic index indicates a wide safety margin between the effective dose and the toxic dose, reducing the risk of toxicity; low bioavailability refers to the fraction of the drug that reaches the systemic circulation unchanged and does not directly relate to the risk of toxicity.

4. A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant. What action should the nurse take when finding the radiation implant in the bed?

• A. Call radiation therapy for assistance
• B. Place the implant in a lead container using long-handled forceps
• C. Leave the implant in the bed and notify the provider
• D. Dispose of the implant in the nearest sharps container

Correct answer: B

Rationale: The correct action for the nurse to take when finding the radiation implant in the bed is to use long-handled forceps to place the implant in a lead container. This procedure is crucial in reducing radiation exposure to both the patient and healthcare providers. Calling radiation therapy for assistance (Choice A) may delay the immediate need for safe handling of the implant. Leaving the implant in the bed and notifying the provider (Choice C) is unsafe and can lead to increased radiation exposure. Disposing of the implant in a sharps container (Choice D) is incorrect as the implant should be placed in a lead container, not a sharps container, to contain the radiation.

5. A client receiving codeine for pain every 4 to 6 hours over 4 days. Which assessment should the nurse perform before administering the next dose?

• A. Auscultate the bowel sounds.
• B. Palpate the ankles for edema.
• C. Observe the skin for bruising.
• D. Measure the body temperature.

Correct answer: A

Rationale: The correct answer is A: Auscultate the bowel sounds. Codeine is known to cause constipation, so it is essential to assess bowel sounds before administering another dose to monitor for potential constipation or bowel motility issues. Palpating the ankles for edema (Choice B) is not directly related to codeine use or its side effects. Observing the skin for bruising (Choice C) is important but not specifically associated with codeine administration. Measuring body temperature (Choice D) is not a priority assessment related to codeine use; monitoring for constipation is more critical in this case.

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