Nursing Elites

1. A client receiving chemotherapy reports severe nausea. What should the nurse implement first?

• A. Administer an antiemetic as prescribed.
• B. Offer the client small, frequent meals.
• C. Provide the client with crackers and water.
• D. Encourage the client to eat a bland diet.

Correct answer: A

Rationale: The correct answer is A: Administer an antiemetic as prescribed. When a client receiving chemotherapy reports severe nausea, the priority action is to administer an antiemetic medication as prescribed. Antiemetics help alleviate nausea and prevent complications associated with chemotherapy, such as dehydration and malnutrition. Options B, C, and D focus on dietary interventions which can be helpful but addressing the severe nausea with antiemetic medication takes precedence to provide immediate relief and ensure the client's comfort and well-being.

2. The nurse is caring for a client with a history of congestive heart failure (CHF) who is receiving digoxin therapy. The client reports seeing halos around lights. Which action should the nurse take?

• A. Assess the client's digoxin level
• B. Increase the client's fluid intake
• C. Check the client's blood pressure
• D. Administer a dose of potassium

Correct answer: A

Rationale: Seeing halos around lights is a classic symptom of digoxin toxicity. The nurse should assess the client's digoxin level to determine if the dose needs to be adjusted or if the medication should be held. Increasing fluid intake or checking blood pressure would not directly address the symptom of halos around lights. Administering a dose of potassium is not indicated without knowing the digoxin level and could potentially worsen the toxicity.

3. A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?

• A. Taking a client's blood pressure
• B. Providing oral hygiene for a client
• C. Assessing a client's pain level
• D. Assisting a client with ambulation

Correct answer: C

Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.

4. What assessment is most important for the nurse to perform for a client with dehydration receiving IV fluids?

• A. Monitor the client’s electrolyte levels.
• B. Check the client’s urine output hourly.
• C. Assess the client’s skin turgor regularly.
• D. Monitor the client’s blood pressure every 15 minutes.

Correct answer: A

Rationale: The correct answer is to monitor the client’s electrolyte levels. When a client is receiving IV fluids for dehydration, it is crucial to assess their electrolyte levels regularly. Dehydration can lead to imbalances in electrolytes, especially sodium and potassium, which are essential for maintaining fluid balance and proper organ function. Checking urine output (Choice B) is important but not as critical as monitoring electrolyte levels. Assessing skin turgor (Choice C) is an indirect method of assessing dehydration but does not provide specific information about electrolyte imbalances. Monitoring blood pressure (Choice D) is important but not the most critical assessment in this scenario as electrolyte imbalances can have a more direct impact on the client's condition.

5. A client with Alzheimer's disease is prescribed donepezil. What is the most important teaching point?

• A. Take the medication as directed for best results.
• B. Report any unusual changes in behavior.
• C. This medication helps improve cognitive function.
• D. This medication is not a cure for Alzheimer's disease.

Correct answer: C

Rationale: The most important teaching point for a client prescribed donepezil is that it helps improve cognitive function. While it is important to take the medication as directed for best results (choice A) and report any unusual changes in behavior (choice B), the key point is that donepezil is not a cure for Alzheimer's disease (choice D). Therefore, the correct answer is C.

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