Nursing Elites

1. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?

• A. Administer furosemide as prescribed.
• B. Administer albumin to increase oncotic pressure.
• C. Elevate the client's legs to reduce swelling.
• D. Administer a sodium-restricted diet.

Correct answer: A

Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.

2. The nurse is developing an educational program for older clients discharged with new antihypertensive medications. The nurse should ensure that the education materials include which characteristics?

• A. Uses pictures to help illustrate complex ideas
• B. Contains a list with definitions of unfamiliar terms
• C. Uses common words with few syllables
• D. All of the above

Correct answer: D

Rationale: The correct answer is D, 'All of the above.' When developing educational materials for older clients with new antihypertensive medications, it is essential to include characteristics such as using pictures to illustrate complex ideas, providing a list with definitions of unfamiliar terms, and using common words with few syllables. These features help enhance understanding and medication adherence, especially for older adults who may have challenges with health literacy. Choices A, B, and C collectively address the need for simplicity, visual support, and clarification of terms in educational materials, making them crucial for effective patient education.

3. When speaking with a group of teens about chemotherapy side effects for cancer, which side effect would the nurse expect this group to be more interested in discussing?

• A. Mouth sores
• B. Fatigue
• C. Diarrhea
• D. Hair loss

Correct answer: D

Rationale: Teens are more likely to be concerned with hair loss when discussing chemotherapy side effects because it is a visible and emotionally impactful side effect for them. While all the listed side effects are important to consider, hair loss can have a significant impact on a teenager's self-image and emotional well-being, making it a key point of interest for this age group. Mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, but they may not carry the same level of emotional weight and visibility as hair loss for teens.

4. A client presses the call bell and requests pain medication for a severe headache. To assess the quality of the client's pain, which approach should the nurse use?

• A. Use the Wong-Baker Faces pain rating scale
• B. Assess vital signs to gauge pain severity
• C. Ask the client to describe the pain
• D. Offer a 1-10 pain scale

Correct answer: C

Rationale: Asking the client to describe the pain is the most appropriate approach to assess the quality of pain. It provides valuable qualitative information that aids in understanding the nature, cause, and potential management strategies for the headache. While pain rating scales like the Wong-Baker Faces scale and using vital signs can help quantify pain severity, they do not offer specific descriptive details that can give insights into the type and characteristics of the pain experienced by the client.

5. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?

• A. Assist a client post cerebral vascular accident to ambulate
• B. Feed a 2-year-old in balanced skeletal traction
• C. Care for a client with discharge orders
• D. Collect a sputum specimen for acid-fast bacillus

Correct answer: C

Rationale: Caring for a client with discharge orders involves tasks that require critical thinking and clinical judgment, which are beyond the scope of a UAP. Delegating this task to a UAP can compromise patient safety and outcomes. The correct answer is C. Choices A, B, and D are appropriate tasks to delegate to a UAP based on their training and scope of practice. Assisting a client to ambulate, feeding a pediatric patient in traction, and collecting a sputum specimen are tasks that can be safely performed by a UAP under appropriate supervision.

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