Nursing Elites

1. A nurse is caring for a client who is postoperative and refuses to use an incentive spirometer following major abdominal surgery. Which of the following actions is the nurse's priority?

• A. Demonstrate how to use the spirometer
• B. Set a realistic postoperative goal
• C. Determine the reasons why the client is refusing
• D. Request that a respiratory therapist discuss the technique

Correct answer: C

Rationale: The priority action for the nurse is to determine the reasons why the client is refusing to use the incentive spirometer. By understanding the client's concerns or issues, the nurse can address them effectively, provide education or support, and encourage the client to comply with the necessary postoperative care. This approach fosters a patient-centered care environment. Demonstrating how to use the spirometer (Choice A) may be important but is not the priority at this moment. Setting a realistic postoperative goal (Choice B) is relevant but not as immediate as understanding the client's refusal. Requesting a respiratory therapist (Choice D) can be considered later if needed, but the nurse's initial focus should be on understanding the client's perspective.

2. A nurse manager assigns a task outside the scope of a nursing assistant. How should the assistant respond?

• A. Refuse the task and report it to the charge nurse.
• B. Perform the task without reporting.
• C. Ask another nurse to perform the task.
• D. Accept the task but document it later.

Correct answer: A

Rationale: When a task is assigned that is outside the scope of a nursing assistant, it is essential for the assistant to refuse the task and report it to the charge nurse. This ensures that tasks are appropriately delegated, maintaining patient safety and adherence to professional standards. Performing the task without reporting can lead to potential risks for the patient and legal implications. Asking another nurse to perform the task may not address the issue of improper delegation. Accepting the task but documenting it later does not resolve the immediate concern of working within the assistant's scope of practice and seeking appropriate delegation.

3. Which intervention is most effective in preventing postoperative complications?

• A. Encourage the patient to drink fluids.
• B. Ambulate the patient as soon as possible.
• C. Perform deep breathing exercises with the patient.
• D. Encourage the patient to perform range of motion exercises.

Correct answer: B

Rationale: The most effective intervention in preventing postoperative complications is to ambulate the patient as soon as possible. Early ambulation helps prevent complications like deep vein thrombosis and pneumonia by enhancing circulation and preventing respiratory issues. Encouraging the patient to drink fluids, perform deep breathing exercises, or range of motion exercises are beneficial interventions, but ambulation is the priority due to its overall impact on preventing various postoperative complications.

4. How can dehydration be assessed in an elderly patient?

• A. Checking skin turgor on the forearm
• B. Assessing for dry mucous membranes
• C. Checking for orthostatic hypotension
• D. Measuring daily weights

Correct answer: A

Rationale: Assessing skin turgor by gently pinching the skin on the forearm is a reliable method to check for dehydration in elderly patients. When the skin is slow to return to its original position, it indicates dehydration. While assessing for dry mucous membranes is also important, checking skin turgor is a more direct method for dehydration assessment. Checking for orthostatic hypotension is more related to circulation status than dehydration. Measuring daily weights is helpful to monitor fluid balance but may not be as immediate or direct in detecting dehydration in elderly patients.

5. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

• A. Giving a glycerin suppository to a client for constipation
• B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache
• C. Discussing dietary changes with a client who has a prescription for a gluten-free diet
• D. Measuring hourly urinary output for a client who is postoperative

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

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