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. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

• A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
• B. Emptying the device every 4 hours.
• C. Replacing the device every 24 hours.
• D. Keeping the device above the level of the surgical site.

Correct answer: A

Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.

3. Before digital removal of a fecal impaction, which type of enema should the nurse give to loosen the feces?

• A. Oil Retention
• B. Saline
• C. Soapy Water
• D. Hypertonic

Correct answer: A

Rationale: An oil retention enema containing mineral oil is the most suitable choice to help soften and loosen a fecal impaction before digital removal. Mineral oil lubricates and softens the stool, facilitating passage. Saline enemas draw water into the colon to promote bowel movements but may not effectively soften a fecal impaction. Soapy water enemas are primarily for cleansing, not softening stool. Hypertonic enemas eliminate fluid from the body and are not appropriate for loosening fecal impactions.

4. A client with a terminal illness is being educated by a healthcare provider about declining resuscitation in a living will. The client asks, “What would happen if I arrived at the ED and I had difficulty breathing?”

• A. We would give you oxygen through a tube in your nose.
• B. We would initiate full resuscitation efforts.
• C. We would consult the living will and provide comfort care.
• D. We would not provide any medical intervention.

Correct answer: C

Rationale: In the scenario described, the client has a living will that declines resuscitation. Therefore, if the client arrives at the emergency department with difficulty breathing, healthcare providers would consult the living will to understand the client's wishes. Providing comfort care, which may include oxygen therapy to alleviate symptoms, aligns with the client's preferences. Option A incorrectly suggests an intervention that goes against the client's wishes. Option B is incorrect because full resuscitation efforts are not in line with the client's choice to decline resuscitation. Option D is also incorrect as it does not consider the client's living will and the need to provide care according to the documented preferences of the client.

5. A client is admitted to the emergency room following an acute asthma attack. Which of the following assessments would be expected by the nurse?

• A. Diffuse expiratory wheezing
• B. Loose, productive cough
• C. No relief from inhaler
• D. Fever and chills

Correct answer: A

Rationale: During an acute asthma attack, one of the expected assessments by the nurse would be diffuse expiratory wheezing. This occurs due to narrowed airways and increased airflow velocity. Choice B, a loose productive cough, is not typically associated with an asthma attack. Choice C, no relief from inhaler, may indicate ineffective treatment but is not a direct assessment finding related to the physical examination. Choice D, fever and chills, are not typical symptoms of an asthma attack and would not be expected findings during the initial assessment of an acute asthma attack.

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