Nursing Elites

1. A nurse on a pediatric care unit is delegating client care. Which of the following tasks should the nurse delegate to an assistive personnel?

• A. Initiate a dietary consult for a toddler
• B. Administer a glycerin suppository to a preschool-age child
• C. Evaluate gastric residual following intermittent feeding of an adolescent
• D. Transport a school-age child to x-ray

Correct answer: D

Rationale: The correct answer is D because transporting a stable child to x-ray is a task that can be safely delegated to an assistive personnel. This task does not require clinical judgment or specialized skills. Choices A, B, and C involve assessments and interventions that require nursing judgment and should be performed by a qualified nurse. Initiating a dietary consult for a toddler involves assessing the child's nutritional needs and must be done by a nurse. Administering a glycerin suppository to a preschool-age child requires medication administration skills and knowledge of appropriate dosages, which are within the nurse's scope of practice. Evaluating gastric residual following intermittent feeding of an adolescent is a clinical assessment that requires interpretation and decision-making based on the findings, making it a nursing responsibility.

2. A nurse is planning care for a client who has chronic renal failure. Which action should the nurse include in the plan of care?

• A. Encourage increased fluid intake
• B. Restrict protein intake to the RDA
• C. Increase dietary potassium
• D. Encourage foods high in sodium

Correct answer: B

Rationale: The correct action the nurse should include in the plan of care for a client with chronic renal failure is to restrict protein intake to the RDA. This is important because limiting protein helps reduce the buildup of waste products that the kidneys are unable to efficiently excrete. Encouraging increased fluid intake (choice A) may further burden the kidneys, increasing the risk of fluid overload. Increasing dietary potassium (choice C) is not recommended in chronic renal failure as impaired kidneys have difficulty regulating potassium levels. Encouraging foods high in sodium (choice D) is also not appropriate as excessive sodium intake can lead to fluid retention and hypertension, which are detrimental in renal failure.

3. A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the nurse include in the teaching?

• A. Inhale the medication deeply for 3-5 seconds
• B. Exhale forcefully before inhaling
• C. Shake the MDI vigorously before use
• D. Hold the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth

Correct answer: A

Rationale: Corrected Rationale: Inhaling the medication deeply for 3-5 seconds and holding the breath for 10 seconds after inhalation ensures effective medication delivery to the lungs. Choice A is the correct instruction for the use of a metered-dose inhaler (MDI). Choice B, exhaling forcefully before inhaling, is incorrect as it can lead to decreased medication delivery. Choice C, shaking the MDI vigorously before use, is also incorrect as excessive shaking can cause the medication to clump. Choice D, holding the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth, is not recommended as it may lead to improper inhalation technique.

4. A nurse is caring for a client who has an indwelling urinary catheter. What should the nurse identify as a sign of catheter occlusion?

• A. Bladder distention
• B. Frequent urination
• C. Dark urine
• D. Increased thirst

Correct answer: A

Rationale: Bladder distention is the correct sign of catheter occlusion. When a catheter is occluded, the urine cannot drain properly, leading to the buildup of urine in the bladder and subsequent distention. Frequent urination, dark urine, and increased thirst are not typical signs of catheter occlusion. Frequent urination can be a sign of conditions like urinary tract infection, dark urine may indicate dehydration or other issues, and increased thirst can be related to various factors like diabetes or medication side effects.

5. A nurse is caring for a client receiving radiation treatments for cancer. The client states he is experiencing dryness, redness, and scaling at the treatment area. Which of the following should the nurse instruct the client to do?

• A. Sit in the sun for 15 minutes per day.
• B. Apply moist heat to the area twice daily.
• C. Liberally apply prescribed lotion to the area.
• D. Wash the affected area daily with antimicrobial soap.

Correct answer: C

Rationale: The nurse should instruct the client to liberally apply prescribed lotion to the treatment area. Prescribed hydrating lotions help soothe and protect irradiated skin, reducing dryness, redness, and scaling. Sitting in the sun can further damage the skin. Applying moist heat may exacerbate the skin condition. Washing the area with antimicrobial soap can be too harsh and further irritate the skin.

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