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. A client reports dizziness when standing up quickly. What advice should the nurse give?

• A. Encourage the client to drink more fluids.
• B. Change positions slowly to prevent dizziness.
• C. Report the symptom to the healthcare provider immediately.
• D. Limit physical activity to avoid triggering dizziness.

Correct answer: B

Rationale: The correct advice for a client experiencing dizziness when standing up quickly is to change positions slowly to prevent dizziness. This symptom is suggestive of postural hypotension, where a sudden change in position can lead to a drop in blood pressure, causing dizziness. Encouraging the client to drink more fluids (Choice A) may be beneficial for other conditions but is not directly related to the prevention of dizziness in this case. Reporting the symptom to the healthcare provider immediately (Choice C) is important if the dizziness is persistent or severe, but the immediate action to prevent it is to change positions slowly. Limiting physical activity (Choice D) may not necessarily address the underlying cause of dizziness in this context.

3. Which of these clients, all in the terminal stage of cancer, is least appropriate to suggest the use of patient-controlled analgesia (PCA) with a pump?

• A. A young adult with a history of Down syndrome
• B. A teenager who reads at a 4th-grade level
• C. An elderly client with numerous arthritic nodules on the hands
• D. A preschooler with intermittent alertness episodes

Correct answer: D

Rationale: The correct answer is D. A preschooler with intermittent alertness episodes is not a suitable candidate for patient-controlled analgesia (PCA) due to their inability to effectively manage the system. In the context of terminal cancer, it is crucial for the patient to be able to utilize the PCA system appropriately to manage pain effectively. Preschoolers may not have the cognitive ability or understanding to operate a PCA pump compared to the other clients. Choices A, B, and C present clients with conditions that do not inherently impede their ability to use a PCA pump effectively.

4. The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?

• A. Weight-bearing exercise
• B. Aerobic exercise
• C. Low-impact exercises such as swimming
• D. Stretching and flexibility exercises

Correct answer: A

Rationale: The correct answer is A: Weight-bearing exercise. Weight-bearing exercise helps build and maintain bone density, which is critical in preventing osteoporosis. Activities like aerobic exercises, stretching, and low-impact exercises such as swimming are beneficial for overall fitness but do not directly contribute to improving bone strength, making them less effective in preventing osteoporosis.

5. A client with cirrhosis is prescribed spironolactone to manage ascites. Which serum laboratory value is most important for the nurse to monitor?

• A. Sodium
• B. Calcium
• C. Magnesium
• D. Potassium

Correct answer: D

Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.

Similar Questions