Nursing Elites

1. A client with cirrhosis of the liver presents with ascites. The physician is to perform a paracentesis. For safety, the nurse should ask the client to:

• A. drink 1000 cc of fluid prior to the procedure to aid in fluid loss.
• B. eat foods low in fat.
• C. empty his bladder prior to the procedure.
• D. assume the prone position.

Correct answer: C

Rationale: When performing a paracentesis, the client must be sitting up to allow the fluid to settle in the lower abdomen. To prevent trauma to the bladder while inserting a needle to aspirate the fluid, the bladder must be empty. Choice A is incorrect as excessive fluid intake can make the procedure more difficult due to increased abdominal distension. Choice B is unrelated to the procedure of paracentesis. Choice D is incorrect as the client should be sitting up, not in the prone position, during the procedure.

2. A nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply.

• A. Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective
• B. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby
• C. Asking the nursing assistant to administer a medication placed at the client's bedside if the client awakens
• D. Conducting client rounds before taking the break

Correct answer: D

Rationale: The nurse is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse’s break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. Conducting client rounds before taking the break is crucial to assess the clients' conditions and address any immediate needs, ensuring their safety. Asking the nursing assistant to contact the health care provider during the nurse’s break is not appropriate as the nurse should handle this responsibility. Leaving the nursing unit to get coffee is not recommended as the nurse should stay within the unit to respond promptly to any client needs. Asking the nursing assistant to administer medication or make clinical decisions is outside the scope of their practice and should not be delegated.

3. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

• A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
• B. Assisting a client who is getting up to ambulate for the first time after surgery
• C. Providing oral care to an unconscious client who requires oral care
• D. Completing the preoperative checklist for a client scheduled for a liver biopsy

Correct answer: C

Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.

4. A client has signed the informed consent for mastectomy of the left breast. On the morning of the surgical procedure, the client asks the nurse several questions about the procedure that make it obvious that she does not have an adequate comprehension of the procedure. What is the most appropriate response by the nurse?

• A. Telling the client that she needed to ask these questions before signing the informed consent for surgery
• B. Contacting the surgeon and requesting that she visit the client to answer her questions
• C. Informing the client that she has the right to cancel the surgical procedure if she wishes
• D. Telling the client that it is her surgeon's responsibility to explain the procedure

Correct answer: B

Rationale: Informed consent is the authorization by a client or a client's legal representative to do something to the client. The surgeon is primarily responsible for explaining the surgical procedure and obtaining informed consent. If the client asks questions that alert the nurse to an inadequacy of comprehension on the client's part, the nurse has the obligation to contact the surgeon. Choice A is incorrect as the client should be allowed to ask questions even after signing the consent for surgery. Choice C is not the most appropriate response, as the primary concern is to address the client's lack of comprehension. Choice D is inaccurate, as while it is the surgeon's responsibility to explain the procedure, in this scenario, the nurse should take immediate action to ensure the client's understanding. Requesting the surgeon to visit and answer the client's questions is the most appropriate response in this situation, as it directly addresses the client's concerns and ensures proper informed consent is obtained.

5. Which of the following devices may be applicable to a bedridden patient to address potential venous insufficiency?

• A. Shear-reducing mattress
• B. Sequential compression devices
• C. Hiking stockings
• D. Non-skid socks

Correct answer: B

Rationale: For a bedridden patient with potential venous insufficiency, sequential compression devices (SCDs) and compression stockings are appropriate choices. SCDs help improve venous return from the lower extremities by applying sequential pressure, aiding circulation. Compression stockings also assist in preventing blood from pooling in the legs by applying pressure to support venous return. Shear-reducing mattresses are not directly related to managing venous insufficiency, as they are designed to reduce friction and shear forces on the skin to prevent pressure ulcers. Non-skid socks are primarily used for fall prevention and have no direct impact on venous insufficiency.

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