Nursing Elites

1. A client who had coronary artery bypass grafting yesterday needs care. What actions can the nurse delegate to the unlicensed assistive personnel (UAP)? (SATA)

• A. administer antibiotics every 4 hrs
• B. Encourage the client to use the spirometer every 4 hours.
• C. Ensure the client wears TED hose or sequential compression devices.
• D. Have the client rate pain on a 0-to-10 scale and report to the nurse.

Correct answer: C

Rationale: The nurse can delegate tasks such as assisting the client to get up in the chair or ambulate to the bathroom, applying TED hose or sequential compression devices, and taking/recording vital signs to the unlicensed assistive personnel (UAP). Using the spirometer should be encouraged every hour the day after surgery by the nurse. Assessing pain using a 0-to-10 scale is a nursing assessment. However, if the client reports pain, the UAP should inform the nurse for a more detailed assessment.

2. A client was exposed to anthrax. Which of the following antibiotics should the nurse plan to administer?

• A. Ciprofloxacin
• B. Fluconazole
• C. Tobramycin
• D. Vancomycin

Correct answer: A

Rationale: In the case of anthrax exposure, the recommended antibiotic for prophylaxis and treatment is Ciprofloxacin. Ciprofloxacin is effective against the anthrax bacterium, Bacillus anthracis. Fluconazole is an antifungal medication, Tobramycin is an aminoglycoside antibiotic used for bacterial infections, and Vancomycin is a glycopeptide antibiotic primarily used for Gram-positive bacterial infections. Therefore, the correct choice is Ciprofloxacin.

3. A healthcare professional auscultates a harsh hollow sound over a client's trachea & larynx. Which action should the healthcare professional take first?

• A. Document findings.
• B. Administer O2 therapy.
• C. Position client in high-Fowler's position.
• D. Administer prescribed albuterol.

Correct answer: A

Rationale: The healthcare professional has identified bronchial breath sounds, which are normal findings over the trachea & larynx, characterized by harsh, hollow, tubular, and blowing sounds. The appropriate initial action for the healthcare professional is to document these normal findings. Oxygen therapy, administering albuterol, or repositioning the client is unnecessary as this finding does not indicate a need for intervention.

4. When teaching a group of clients about emergency care for a snake bite, which of the following information should the nurse include?

• A. Raise the affected extremity above the level of the heart.
• B. Immobilize the affected extremity with a splint
• C. Apply ice to the bite area
• D. Apply a tourniquet to the affected extremity.

Correct answer: B

Rationale: In cases of snake bites, it is essential to immobilize the affected extremity with a splint to prevent the spread of venom throughout the body. Raising the extremity above the heart level can promote venom spread, and applying ice or a tourniquet can worsen the condition. Immobilization helps reduce movement and slows the circulation of venom, aiding in the prevention of further complications.

5. A client has a mediastinal chest tube. Which symptom requires the nurse's immediate intervention?

• A. Production of pink sputum
• B. Tracheal deviation
• C. Drainage greater than 70 mL/hr
• D. Sudden onset of shortness of breath

Correct answer: B

Rationale: Immediate intervention is required if the client exhibits tracheal deviation as it could indicate a tension pneumothorax, a life-threatening condition that requires prompt attention to prevent respiratory compromise. Production of pink sputum may indicate bleeding but would not be as immediately life-threatening as tracheal deviation. Drainage greater than 70 mL/hr could indicate hemorrhage, which also requires attention but is not as urgent as tracheal deviation. Sudden onset of shortness of breath could indicate various issues, including dislodgment of the tube or pneumothorax, which require intervention but are not as critical as tracheal deviation in this context.

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