Nursing Elites

1. A young adult client is receiving instruction from a healthcare provider about health promotion and illness prevention. Which of the following statements indicates understanding?

• A. “I had my immunizations as a child, so I’m protected in that area.”
• B. “It is important to schedule routine health care visits even if I am feeling well.”
• C. “I will go to an urgent care center for my routine medical care.”
• D. “There’s no reason to seek help if I am feeling stressed as it’s just part of life.”

Correct answer: B

Rationale: The correct answer is B. Scheduling routine health care visits, even when feeling well, is crucial for early detection and prevention of health issues. This proactive approach allows healthcare providers to monitor overall health, provide preventive care, and address any emerging health concerns promptly. Choice A is incorrect because past immunizations do not cover all potential diseases; regular check-ups are still necessary. Choice C is incorrect as urgent care centers are not designed for routine medical care. Choice D is incorrect as seeking help for stress is important for mental well-being and should not be dismissed as a normal part of life.

2. When assessing a client reporting increased pain after physical therapy, which question should the nurse ask to evaluate the quality of the pain?

• A. Is the pain sharp or dull?
• B. Does the pain radiate to other areas?
• C. Does the pain increase with movement?
• D. Can you rate your pain on a scale of 1 to 10?

Correct answer: A

Rationale: The correct question to ask when assessing the quality of a client's pain is whether the pain is sharp or dull. This helps in understanding the characteristics of the pain being experienced. Choice B, asking if the pain radiates to other areas, focuses more on pain distribution rather than quality. Choice C, inquiring if the pain increases with movement, pertains to aggravating factors rather than pain quality. Choice D, requesting the client to rate pain on a scale of 1 to 10, is related to pain intensity rather than quality.

3. 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.

4. The healthcare provider is caring for a client with a suspected deep vein thrombosis (DVT). Which assessment finding should the healthcare provider report to the healthcare provider?

• A. Swelling and redness in the affected leg
• B. Pain in the affected leg
• C. Warmth and tenderness in the affected leg
• D. A positive Homans' sign

Correct answer: D

Rationale: A positive Homans' sign is a classic sign associated with deep vein thrombosis (DVT) and indicates the presence of a blood clot. This finding is crucial to report to the healthcare provider promptly for further evaluation and treatment. Swelling, redness, pain, warmth, and tenderness in the affected leg are common signs of DVT, but a positive Homans' sign specifically points towards a potential blood clot, making it the priority finding to be reported. Reporting other symptoms may also be important, but a positive Homans' sign is more specific to DVT and requires immediate attention.

5. Which action by the nurse will be the most important for preventing skin impairment in a mobile patient with local nerve damage?

• A. Insert an indwelling urinary catheter.
• B. Limit caloric and protein intake.
• C. Turn the patient every 2 hours.
• D. Assess for pain during a bath.

Correct answer: D

Rationale: The most important action for preventing skin impairment in a mobile patient with local nerve damage is to assess for pain during a bath. Assessing pain during a bath helps in evaluating sensory nerve function by checking for touch, pain, heat, cold, and pressure. This assessment is crucial in identifying areas of potential skin breakdown and implementing preventive measures. Inserting an indwelling urinary catheter (Choice A) is not directly related to preventing skin impairment in this context. Limiting caloric and protein intake (Choice B) is not pertinent to skin impairment prevention for a mobile patient with local nerve damage. While turning the patient every 2 hours (Choice C) is a good practice for preventing pressure ulcers, in this case, assessing for pain during a bath is more directly related to preventing skin impairment associated with nerve damage.

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