Nursing Elites

1. A client has experienced a CVA with right hemiparesis and is ready for discharge from the hospital to a long-term care facility for rehab. To provide optimal continuity of care, the nurse should do all of the following except:

• A. document the current functional status
• B. have the physician fax a report to the receiving facility
• C. copy appropriate parts of the medical record for transport to the receiving facility
• D. phone a report to the facility

Correct answer: B

Rationale: To ensure optimal continuity of care for a client transitioning to a long-term care facility for rehab after a CVA, the nurse plays a crucial role in communication. Documenting the current functional status is essential for the receiving facility to plan appropriate care. Copying relevant parts of the medical record for transport provides important background information. Phoning a report directly to the facility is a direct and effective way to communicate the client's condition and care plan. However, having the physician fax a report to the receiving facility introduces an extra step that may delay essential information transfer and increase the risk of miscommunication. Therefore, it is not the optimal choice for ensuring seamless continuity of care.

2. What is a common side effect of Rifampin concerning the client's contact lenses?

• A. The client's urine might turn blue.
• B. The client remains infectious to others for 48 hours.
• C. The client's contact lenses might be stained orange.
• D. The client's skin might take on a crimson glow.

Correct answer: C

Rationale: The correct answer is that the client's contact lenses might be stained orange. Rifampin has the unusual effect of turning body fluids an orange color. Soft contact lenses might become permanently stained, making this an important side effect for the client to be aware of. Choices A, B, and D are incorrect. There is no documented effect of Rifampin causing the client's urine to turn blue, the client remaining infectious for 48 hours, or the client's skin taking on a crimson glow.

3. A client is on a clear liquid diet. She drinks half of a 12-ounce juice, 4 ounces of soup, and has a 6-ounce JELLO®. How many milliliters of fluid did the patient ingest?

• A. 440 ml
• B. 480 ml
• C. 220 ml
• D. 660 ml

Correct answer: B

Rationale: To calculate the total amount of fluid ingested, convert the ounces to milliliters. Given that 1 ounce is equal to 30 ml, the breakdown is as follows: Juice (6 ounces): 6 x 30 = 180 ml. Soup (4 ounces): 4 x 30 = 120 ml. JELLO® (6 ounces): 6 x 30 = 180 ml. Adding these together: 180 ml (juice) + 120 ml (soup) + 180 ml (JELLO®) = 480 ml. Therefore, the patient ingested a total of 480 ml of fluid. It's important to note that gelatin, ice cream, and similar items that are liquid at room temperature should be considered as fluids. Choice A, 440 ml, is incorrect as it does not account for the correct calculation. Choice C, 220 ml, is incorrect as it is significantly lower than the correct total. Choice D, 660 ml, is incorrect as it overestimates the total fluid intake.

4. Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?

• A. "Make it a stat delivery."?
• B. "Please do it as soon as you can after break."?
• C. "This client is delirious, and we're worried about urinary sepsis."?
• D. "Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately."?

Correct answer: D

Rationale: Effective delegation depends on clear, concise direction that leaves no room for question or interpretation on the part of the one being delegated to. In this scenario, the most appropriate direction is to ensure the urine specimen is collected promptly and delivered to the lab immediately. Choice A is too vague and does not specify the urgency required. Choice B does not emphasize the immediate need for the specimen to be delivered. Choice C introduces unnecessary medical information that is beyond the scope of a nursing assistant and may cause confusion. Therefore, choice D is the correct answer as it provides clear instructions for immediate action without room for misunderstanding.

5. Why is client and family communication and education concerning restraints essential?

• A. confuses both groups further
• B. helps with coping and stress levels
• C. encourages cooperation with the client and family
• D. puts the responsibility on the client and family, not the nurse

Correct answer: C

Rationale: Client and family communication and education concerning restraints are essential to encourage cooperation. When the client and family understand the purpose and expected benefits of restraints, they are more likely to cooperate. This understanding can help prevent well-meaning family members from releasing restraints due to confusion or lack of information. Therefore, choice C is correct. Choices A, B, and D are incorrect because confusing both groups further, helping with coping and stress levels, and shifting responsibility to the client and family are not the primary goals of communication and education concerning restraints.

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