Nursing Elites

1. A client with a chest tube following thoracic surgery needs care. Which task should the nurse delegate to an assistive personnel?

• A. Teach deep breathing and coughing to the client.
• B. Assist the client to select food choices from the menu.
• C. Evaluate the client’s response to pain medication.
• D. Monitor the characteristics of the client's chest tube drainage.

Correct answer: B

Rationale: The correct answer is B because assisting the client with food choices is a task that can be safely delegated to assistive personnel. This task does not require nursing judgment or specialized skills. Choices A, C, and D involve assessing the client's condition, response to treatment, and monitoring critical aspects of care, which are nursing responsibilities that necessitate specialized knowledge and judgment. Teaching deep breathing and coughing (A), evaluating pain medication response (C), and monitoring chest tube drainage (D) require a higher level of training and expertise that should be performed by the nurse.

2. In a mass casualty scenario at a child day care center, which child would the triage nurse prioritize for treatment last?

• A. An infant with intermittent bulging anterior fontanel between crying episodes
• B. A toddler with severe deep abrasions covering over 98% of the body
• C. A preschooler with 1 lower leg fracture and the other leg with an upper leg fracture
• D. A school-age child with singed eyebrows and hair on the arms

Correct answer: B

Rationale: In a mass casualty scenario, the triage nurse would prioritize the toddler with severe deep abrasions covering over 98% of the body for treatment last. This child is categorized as 'expectant' due to the extensive injuries, which are unlikely to be survivable even with immediate treatment. The other choices describe injuries that are serious but have a higher likelihood of survival with appropriate and timely intervention. The infant with an intermittent bulging anterior fontanel may have increased intracranial pressure requiring urgent evaluation, the preschooler with leg fractures can be stabilized and treated effectively, and the school-age child with singed hair likely has superficial burns which can be managed promptly.

3. The healthcare professional is preparing to administer a tuberculin skin test. Which site is most appropriate for this injection?

• A. Deltoid muscle
• B. Vastus lateralis muscle
• C. Abdomen
• D. Inner forearm

Correct answer: D

Rationale: The inner forearm is the most appropriate site for administering a tuberculin skin test. This test requires an intradermal injection, which is administered just below the surface of the skin. The inner forearm provides a flat, easily accessible surface for this type of injection. Choices A, B, and C are incorrect because the tuberculin skin test should not be administered into a muscle (deltoid muscle or vastus lateralis muscle) or into the abdomen. The test requires precise placement within the dermal layer of the skin on the inner forearm to accurately assess for a reaction.

4. A client has a closed wound drainage system. Which of the following actions should the nurse take?

• A. Avoid pressing the container down to create a vacuum
• B. Wear sterile gloves while handling the drainage system
• C. Reset the container with the drainage port closed
• D. Maintain the drain in a dependent position to facilitate drainage

Correct answer: D

Rationale: In a closed wound drainage system, it is essential to maintain the drain in a dependent position to allow for proper drainage. Gravity aids in the flow of drainage, preventing fluid backflow or pooling. Avoiding pressing the container down to create a vacuum (Choice A) is crucial as it can lead to complications in the system. Wearing sterile gloves (Choice B) is important for infection control when handling the drainage system. Resetting the container with the drainage port closed (Choice C) is incorrect as it can cause spillage and contamination of the surrounding area.

5. A client is reporting pain to a nurse. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements?

• A. "I'm having mild pain."
• B. "The pain is like a dull ache in my stomach."
• C. "I notice that the pain gets worse after I eat."
• D. "The pain makes me feel nauseous."

Correct answer: B

Rationale: The correct answer is B. When documenting the quality of pain, it is essential to record the client's description of how the pain feels in their own words. Choice A simply states the intensity of pain but does not describe its quality. Choices C and D provide information related to aggravating factors and associated symptoms, respectively, but they do not describe the quality of pain. Therefore, choice B, which describes the pain as a dull ache in the stomach, is the most appropriate statement to document for assessing the quality of the client's pain.

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