Nursing Elites

1. When planning care for a newly admitted elderly client who is severely dehydrated, which task is appropriate to assign to an unlicensed assistive personnel (UAP)?

• A. Converse with the client to determine if the mucous membranes are impaired
• B. Report hourly outputs of less than 30 ml/hr
• C. Monitor client's ability to move in the bed
• D. Check skin turgor every 4 hours

Correct answer: B

Rationale: The correct answer is B. Assigning the UAP to report hourly outputs of less than 30 ml/hr is appropriate as it falls within their scope of practice and does not involve making clinical assessments or decisions. Choices A, C, and D involve tasks that require a higher level of clinical judgment and training. Choice A requires assessing mucous membranes, which is beyond the UAP's scope. Choice C involves assessing movement ability, which requires more specialized training. Choice D involves assessing skin turgor, which also requires a higher level of clinical judgment.

2. A nurse is teaching an older adult client who has type 2 diabetes mellitus about how to care for corns and calluses on her toes. Which of the following statements by the client indicates an understanding of the teaching?

• A. I can place an oval corn pad over toes that have corns as long as I remove the pad weekly
• B. I should soak my feet in warm water daily to soften corns and calluses
• C. I can apply lotion to soften calluses as long as I don’t put lotion between my toes
• D. I should use an over the counter liquid medication to remove corns

Correct answer: C

Rationale: Applying lotion to the feet, avoiding between toes, is correct; over-the-counter treatments and soaking are not recommended.

3. A client needs to maintain a positive nitrogen balance for wound healing. Which of the following food items should the nurse recommend as a good source of complete protein?

• A. Cheddar cheese
• B. White rice
• C. Apples
• D. Green beans

Correct answer: A

Rationale: Cheddar cheese is the correct answer as it is a good source of complete protein that contains all essential amino acids required for maintaining a positive nitrogen balance for wound healing. Complete proteins provide all essential amino acids needed by the body. White rice, apples, and green beans do not offer complete proteins like cheddar cheese, making them inadequate choices for this purpose.

4. A healthcare professional is preparing to transfer a client who can bear weight on one leg from the bed to a chair. After securing a safe environment, which of the following actions should the healthcare professional take next?

• A. Assess the client for orthostatic hypotension
• B. Obtain a gait belt
• C. Ensure the client has proper footwear
• D. Ask the client to perform range-of-motion exercises

Correct answer: A

Rationale: Assessing the client for orthostatic hypotension is the priority before transferring a client who can bear weight on one leg. This assessment helps identify the risk of dizziness or fainting when the client moves from a supine to an upright position. Obtaining a gait belt may be necessary for the transfer, but assessing for orthostatic hypotension comes first to ensure the safety of the client. Ensuring the client has proper footwear is important for preventing falls during ambulation but is not the immediate next step in this situation. Asking the client to perform range-of-motion exercises is not necessary before the transfer and does not address the immediate safety concern of orthostatic hypotension.

5. A client who is lactating is being taught about taking medications by a nurse. Which of the following actions should the nurse recommend to minimize the entry of medication into breast milk?

• A. Drink 8 oz of water with each dose of medication.
• B. Use medications that have a short half-life.
• C. Take each dose right after breastfeeding.
• D. Pump breast milk and discard it prior to feeding the newborn.

Correct answer: C

Rationale: Taking medications immediately after breastfeeding helps minimize the amount of medication that enters breast milk. By doing so, there is a longer interval between the medication intake and the next breastfeeding session, reducing the concentration of the medication in breast milk. Options A and B are incorrect as drinking water with medication or using medications with a short half-life do not directly minimize the entry of medication into breast milk. Option D is unnecessary and wasteful as pumping and discarding breast milk before feeding is not as effective as timing medication intake with breastfeeding to reduce medication transfer into breast milk.

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