Nursing Elites

1. A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?

• A. Taking a client's blood pressure
• B. Providing oral hygiene for a client
• C. Assessing a client's pain level
• D. Assisting a client with ambulation

Correct answer: C

Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.

2. The nurse is caring for a client with an acute myocardial infarction. Which symptom requires immediate intervention?

• A. Dizziness
• B. Shortness of breath
• C. Severe chest pain
• D. Nausea and vomiting

Correct answer: C

Rationale: Severe chest pain is the hallmark symptom of an acute myocardial infarction (heart attack) and requires immediate intervention to prevent further damage to the heart muscle. Chest pain in this context is often described as crushing, pressure, tightness, or heaviness. It can radiate to the arms, neck, jaw, back, or upper abdomen. Other symptoms like dizziness, shortness of breath, nausea, and vomiting may also occur in acute myocardial infarction, but chest pain is the most critical sign requiring prompt action as it signifies inadequate blood flow to the heart muscle. Shortness of breath may indicate heart failure, while nausea and vomiting can be associated with the sympathetic response to myocardial infarction. Dizziness could result from decreased cardiac output but is not as specific to myocardial infarction as severe chest pain.

3. An 11-year-old client admitted to the mental health unit after threatening self-harm. What is the best activity to establish rapport and promote coping?

• A. Bring the client to the team meeting to discuss the treatment plan.
• B. Play a board game with the client and start discussing stressors.
• C. Explain the purpose of each medication the client is taking.
• D. Ask the client to write feelings in a journal and review together.

Correct answer: B

Rationale: Playing a board game with the client is an effective way to establish rapport in a relaxed setting, allowing the client to open up about stressors. This activity promotes coping by creating a safe and engaging environment for the client to express their feelings. Choices A, C, and D may not be suitable initially as they involve more formal or intrusive approaches that may not be suitable for building rapport with a client experiencing emotional distress.

4. A client with chronic liver disease is prescribed lactulose. Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?

• A. Bilirubin level
• B. Serum ammonia level
• C. Serum potassium level
• D. Albumin level

Correct answer: B

Rationale: The correct answer is B: Serum ammonia level. Lactulose is used to lower serum ammonia levels in clients with chronic liver disease, particularly in cases of hepatic encephalopathy. Monitoring serum ammonia levels is crucial to evaluate the effectiveness of lactulose in managing hepatic encephalopathy. Choices A, C, and D are incorrect because they are not directly related to the action or evaluation of lactulose in chronic liver disease.

5. When speaking with a group of teens about chemotherapy side effects for cancer, which side effect would the nurse expect this group to be more interested in discussing?

• A. Mouth sores
• B. Fatigue
• C. Diarrhea
• D. Hair loss

Correct answer: D

Rationale: Teens are more likely to be concerned with hair loss when discussing chemotherapy side effects because it is a visible and emotionally impactful side effect for them. While all the listed side effects are important to consider, hair loss can have a significant impact on a teenager's self-image and emotional well-being, making it a key point of interest for this age group. Mouth sores, fatigue, and diarrhea are also common side effects of chemotherapy, but they may not carry the same level of emotional weight and visibility as hair loss for teens.

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