Nursing Elites

1. A nurse is observing an assistive personnel (AP) caring for a client. For which of the following actions by the AP should the nurse intervene?

• A. Providing care in the hallway
• B. Reporting client information in the hallway
• C. Helping another client use the restroom
• D. Feeding the client too quickly

Correct answer: B

Rationale: The correct answer is B because reporting client information in the hallway violates privacy regulations, compromising patient confidentiality. Providing care in the hallway (choice A) may not be ideal but is not a direct violation. Helping another client use the restroom (choice C) shows the AP's willingness to assist but is not a concern unless it compromises the current client's safety. Feeding the client too quickly (choice D) is a potential concern for aspiration but may not require immediate intervention as addressing hydration and swallowing strategies can help prevent complications.

2. A nurse in a long-term care facility is assisting with an in-service for newly hired assistive personnel about legal issues within the facility. Which of the following should the nurse include as an example of assault?

• A. Threatening to withhold food from a client
• B. Informing a client about an upcoming procedure
• C. Informing a client about risks of refusing treatment
• D. Informing a client that they will be given an injection against their will

Correct answer: D

Rationale: The correct answer is D because assault involves threatening a client with harm or unwanted procedures. In this scenario, informing a client that they will be given an injection against their will constitutes assault. Choices A, B, and C do not involve the element of threatening harm or unwanted procedures, making them incorrect. Choice A is more related to neglect, choice B is related to informing the client about a procedure, and choice C is related to informed consent and refusal of treatment, not assault.

3. A client with a tracheostomy is experiencing increased secretions and labored breathing. What should the nurse do first?

• A. Administer a bronchodilator
• B. Suction the tracheostomy
• C. Encourage the client to cough
• D. Notify the provider

Correct answer: B

Rationale: The correct answer is to suction the tracheostomy first. When a client with a tracheostomy is experiencing increased secretions and labored breathing, suctioning the tracheostomy is the priority intervention to clear the airway and improve breathing. Administering a bronchodilator (Choice A) may help with breathing but should come after ensuring the airway is clear. Encouraging the client to cough (Choice C) may not be effective in clearing secretions from the tracheostomy. Notifying the provider (Choice D) can be done after ensuring immediate airway clearance.

4. What are early indicators of dehydration?

• A. Dry mouth
• B. Increased thirst
• C. Decreased urine output
• D. Dizziness

Correct answer: A

Rationale: The correct answer is A, dry mouth, and B, increased thirst are early indicators of dehydration. Dry mouth occurs when the body is dehydrated, and increased thirst is the body's way of trying to increase fluid intake to combat dehydration. Choices C and D, decreased urine output and dizziness, can be signs of severe dehydration but are not typically considered early indicators.

5. A nurse is reinforcing teaching about cane use for a client with left-leg weakness. What should the nurse instruct the client to do?

• A. Use the cane on the weak side
• B. Maintain two points of support on the ground at all times
• C. Advance the cane 30 to 45 cm with each step
• D. Advance the cane and the strong leg simultaneously

Correct answer: B

Rationale: The correct answer is B: Maintain two points of support on the ground at all times. When using a cane for left-leg weakness, the client should hold the cane in the right hand and advance the cane and the weak leg simultaneously. This technique provides the necessary support and stability. Option A is incorrect because the cane should be used on the side opposite the weakness to provide support. Option C is incorrect as advancing the cane too far with each step may cause the client to lose balance. Option D is incorrect because advancing the cane and the strong leg simultaneously does not provide the needed support for the weakened leg.

Similar Questions