Nursing Elites

1. A client has had their diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?

• A. smoothie
• B. sliced banana
• C. pancakes
• D. sunny side up (fried) eggs

Correct answer: D

Rationale: The correct answer is 'D: sunny side up (fried) eggs.' Fried eggs should be removed as they are not suitable for a mechanical soft diet due to their texture. The yolk of a fried egg is usually too hard and can be difficult for a client on a mechanical soft diet to chew and swallow. Poached or scrambled eggs are better alternatives for this diet as they are softer and easier to consume. Choices A, B, and C are all suitable for a mechanical soft diet as they are softer in texture and easier to chew and swallow.

2. When assessing the skin of an immobilized patient, what should the nurse do?

• A. Assess the skin every 4 hours.
• B. Limit the amount of fluid intake.
• C. Use a standardized tool such as the Braden Scale.
• D. Have special times for inspection to not interrupt routine care.

Correct answer: C

Rationale: When assessing the skin of an immobilized patient, it is essential to use a standardized tool like the Braden Scale. This tool helps in systematically evaluating the patient's risk of developing pressure ulcers. Assessing the skin every 4 hours (Choice A) may be too frequent or unnecessary unless there are specific concerns or orders. Limiting fluid intake (Choice B) is not directly related to skin assessment in an immobilized patient. Having special times for inspection to avoid interrupting routine care (Choice D) is not as crucial as using a standardized tool for consistent and comprehensive skin assessment.

3. A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention?

• A. Providing cholesterol screening
• B. Teaching about a healthy diet
• C. Providing information about antihypertensive medications
• D. Developing a list of cardiac rehabilitation programs

Correct answer: B

Rationale: Teaching about a healthy diet is considered a primary prevention activity. Primary prevention aims to prevent the onset of a disease or health problem. Educating individuals on healthy lifestyle choices, such as diet modification, falls under primary prevention. Providing cholesterol screening (choice A) is a secondary prevention measure aimed at early detection. Offering information about antihypertensive medications (choice C) falls under secondary prevention, focusing on controlling risk factors. Developing a list of cardiac rehabilitation programs (choice D) is part of tertiary prevention, focusing on rehabilitation and improving outcomes post-disease onset.

4. A healthcare provider is preparing to insert an IV catheter into a client's arm before starting IV fluid therapy. Which of the following interventions should the provider implement to prevent infection?

• A. Thread the IV catheter so that the hub rests at the insertion site
• B. Shave excess hair from around the insertion site
• C. Cleanse the site with hydrogen peroxide before IV catheter insertion
• D. Palpate the site carefully just before inserting the IV catheter

Correct answer: A

Rationale: Inserting the IV catheter so that the hub rests at the insertion site reduces the risk of contamination along the length of the catheter. This technique helps prevent introducing microbes into the bloodstream during the catheter insertion process. Shaving excess hair is unnecessary and can increase the risk of skin irritation and infection. Cleansing the site with hydrogen peroxide is outdated as it can cause tissue damage and delay wound healing. Palpating the site just before insertion can introduce bacteria from the skin surface into the insertion site, increasing the risk of infection.

5. Which task can the RN delegate to an unlicensed assistive personnel (UAP)?

• A. Take a history on a newly admitted client
• B. Adjust the rate of a gastric tube feeding
• C. Check the blood pressure of a 2-hour postoperative client
• D. Check on a client receiving chemotherapy

Correct answer: C

Rationale: The correct answer is C. Checking the blood pressure of a 2-hour postoperative client is a task that can be safely delegated to an unlicensed assistive personnel (UAP) as it falls within their scope of practice. This task is routine and does not require specialized nursing knowledge or critical decision-making. Options A, B, and D involve tasks that require a higher level of training and critical thinking beyond the scope of a UAP. Taking a history, adjusting tube feeding rates, and monitoring a client receiving chemotherapy are responsibilities that should be performed by licensed healthcare providers who have the necessary skills and training.

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