Nursing Elites

1. A nurse is caring for a group of clients. Which of the following clients should the nurse assign to an assistive personnel (AP)?

• A. Client who has chronic obstructive pulmonary disease and needs guidance with incentive spirometry
• B. Client who has awoken following a bronchoscopy and requests a drink
• C. Client who had a myocardial infarction 3 days ago and reports chest discomfort
• D. Client who had a cerebrovascular accident 2 days ago and needs help toileting

Correct answer: D

Rationale: The correct answer is D because the client who had a cerebrovascular accident 2 days ago and needs help toileting is stable and the task is appropriate for delegation to an assistive personnel (AP). Choices A, B, and C involve clients with more complex care needs that require the expertise of a nurse. Choice A involves providing guidance with incentive spirometry, which requires specialized knowledge and assessment skills. Choice B involves a client who has just undergone a bronchoscopy, so close monitoring is essential to assess for any complications. Choice C involves a client who had a myocardial infarction 3 days ago and is reporting chest discomfort, which could indicate a potential cardiac issue requiring immediate nursing assessment and intervention.

2. While providing education about the use of lorazepam, which of the following should be included?

• A. It can cause dependency
• B. It can be taken with alcohol
• C. It has no side effects
• D. It is a stimulant

Correct answer: A

Rationale: The correct answer is A: 'It can cause dependency.' Lorazepam is a benzodiazepine known to cause dependency, so it is crucial for clients to be informed about this potential risk. Choice B is incorrect as combining lorazepam with alcohol can lead to increased sedation and other adverse effects. Choice C is incorrect because lorazepam, like any medication, can have side effects such as drowsiness, dizziness, or confusion. Choice D is also incorrect as lorazepam is a sedative-hypnotic medication, not a stimulant.

3. A nurse is caring for a client receiving a dopamine infusion via a peripheral IV. Which of the following actions should the nurse take if the IV site appears infiltrated?

• A. Stop the infusion.
• B. Slow the infusion.
• C. Apply a warm compress to the site.
• D. Apply a cold compress to the site.

Correct answer: A

Rationale: Corrected Rationale: If infiltration is suspected, the nurse should immediately stop the dopamine infusion to prevent further damage to the surrounding tissue. Choice A is the correct answer because continuing the infusion can lead to tissue damage and compromise the client's care. Slowing the infusion (Choice B) is not sufficient to prevent harm and may still cause damage. Applying a warm compress (Choice C) or a cold compress (Choice D) is not the recommended action for infiltration; stopping the infusion is crucial to prevent complications.

4. A patient is scheduled for cataract surgery but decides to cancel, stating 'I see just fine.' Which of the following responses should the nurse make?

• A. That’s not a good idea; the surgery is necessary
• B. Share with me more about the thoughts that are concerning you
• C. You should trust your doctor’s advice
• D. You can always reschedule the surgery later

Correct answer: B

Rationale: The correct response is to encourage the patient to share more about their concerns. This approach helps the nurse understand the patient's perspective and allows for a supportive discussion. Choice A is dismissive and does not address the patient's feelings. Choice C may undermine the patient's autonomy and decision-making. Choice D suggests delaying without addressing the patient's current decision.

5. A nurse is caring for a toddler diagnosed with respiratory syncytial virus (RSV). Which of the following actions should the nurse take?

• A. Use a designated stethoscope when caring for the toddler
• B. Wear an N95 respirator mask
• C. Remove the disposable gown after leaving the toddler’s room
• D. Place the toddler in a room with negative air pressure

Correct answer: A

Rationale: Using a designated stethoscope is the correct action when caring for a toddler diagnosed with RSV. This measure helps prevent the spread of infection to other clients by reducing the risk of contamination. Wearing an N95 respirator mask is not necessary for routine care of a toddler with RSV unless performing aerosol-generating procedures. Removing the disposable gown after leaving the toddler's room is important for infection control but not specific to RSV care. Placing the toddler in a room with negative air pressure is not a standard practice for managing RSV in toddlers.

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