Nursing Elites

1. A nurse on a med-surg unit is teaching a newly licensed nurse about tasks to delegate to APs. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

• A. An AP may take orthostatic blood pressure measurements from a client who reports dizziness.
• B. An AP may monitor the peripheral IV insertion site of a client who is receiving replacement fluids.
• C. An AP may perform a central line dressing change for a client who is ready for discharge.
• D. An AP may ambulate a client who had a stroke 2 days ago.

Correct answer: D

Rationale: The correct answer is D. Delegating the task of ambulating a client who had a stroke 2 days ago to an AP is appropriate. This task falls within the scope of practice for an AP and can help promote mobility and prevent complications. Choices A, B, and C involve more complex nursing assessments or procedures that require a higher level of training and expertise. Taking orthostatic blood pressure measurements, monitoring a peripheral IV insertion site, and performing a central line dressing change should be tasks performed by licensed nurses to ensure proper assessment and management of the client's condition.

2. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler?

• A. Immediately after exhalation.
• B. During the inhalation.
• C. At the end of three inhalations.
• D. Immediately after inhalation.

Correct answer: B

Rationale: The correct answer is B: 'During the inhalation.' Administering the medication while inhaling ensures proper delivery to the lungs. Inhaling the medication allows it to reach the lungs effectively for optimal therapeutic benefit. Choices A, C, and D are incorrect because administering the medication after exhalation or at the end of inhalations may result in improper drug delivery and reduced therapeutic effects.

3. The healthcare provider is caring for a client with a history of atrial fibrillation. Which assessment finding would be most concerning?

• A. Blood pressure of 150/90 mmHg
• B. Irregular heart rhythm
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is the most concerning assessment finding in a client with a history of atrial fibrillation. It can indicate a worsening of the condition, pulmonary edema, or the development of a complication such as heart failure. A blood pressure of 150/90 mmHg, while elevated, is not as immediately concerning as respiratory distress in this context. An irregular heart rhythm is expected in atrial fibrillation and may not necessarily be a new or concerning finding. Fatigue is a common symptom in atrial fibrillation but is not as acutely concerning as shortness of breath, which may indicate compromised oxygenation and circulation.

4. A healthcare professional is preparing to admit a client suspected of having pulmonary tuberculosis. Which of the following actions should the healthcare professional plan to perform first?

• A. Implement airborne precautions.
• B. Obtain a sputum culture.
• C. Administer antituberculosis medications.
• D. Recommend a screening test for close contacts.

Correct answer: A

Rationale: The initial priority when admitting a client suspected of having pulmonary tuberculosis is to implement airborne precautions to prevent the spread of the disease. Airborne precautions include wearing a mask and placing the client in a negative pressure room. Obtaining a sputum culture is essential for confirming the diagnosis, but ensuring infection control measures come first to protect others. Administering antituberculosis medications is important but should be initiated after implementing necessary precautions. Recommending a screening test for close contacts is relevant but is a secondary concern compared to immediate infection control measures.

5. A mother of a child with a neural tube defect asks the nurse what she can do to decrease the chances of having another baby with a neural tube defect. What is the best response by the nurse?

• A. Folic acid should be taken before and after conception.
• B. Multivitamin supplements are recommended during pregnancy.
• C. A well-balanced diet promotes normal fetal development.
• D. Increased dietary iron improves the health of mother and fetus.

Correct answer: A

Rationale: The correct answer is A: 'Folic acid should be taken before and after conception.' Folic acid supplementation before and during early pregnancy has been shown to significantly reduce the risk of neural tube defects. Choice B is incorrect because while multivitamin supplements are beneficial during pregnancy, the specific focus for preventing neural tube defects is on folic acid. Choice C is a general statement about a well-balanced diet and does not specifically address neural tube defects. Choice D is incorrect as it focuses on dietary iron, which is important for overall health but not specifically proven to prevent neural tube defects.

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