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 providing teaching to a client with a new diagnosis of diabetes mellitus. Which instruction should the nurse give to the client to monitor for hypoglycemia?

• A. Monitor for polyuria
• B. Monitor for diaphoresis
• C. Monitor for abdominal pain
• D. Monitor for thirst

Correct answer: B

Rationale: The correct answer is B: 'Monitor for diaphoresis.' Diaphoresis, which refers to excessive sweating, is a common symptom of hypoglycemia. It indicates a low blood sugar level and should prompt immediate treatment. Polyuria (excessive urination), abdominal pain, and thirst are not typically associated with hypoglycemia. Polyuria is more commonly linked to hyperglycemia, while abdominal pain and thirst are not specific symptoms of hypoglycemia.

3. A nurse is providing discharge instructions for a client after surgery. Which of the following should be included?

• A. Resume normal activities immediately
• B. Monitor for signs of infection
• C. Avoid all physical activity for 1 month
• D. Take pain medications only as needed

Correct answer: B

Rationale: The correct answer is B: 'Monitor for signs of infection.' After surgery, it is essential for clients to watch for signs of infection, such as increased redness, swelling, or drainage at the incision site. Choice A is incorrect because resuming normal activities immediately after surgery can be harmful. Choice C is incorrect as complete avoidance of physical activity for a month is typically not necessary and can lead to complications like blood clots. Choice D is incorrect as taking pain medications only as needed may not provide adequate pain management post-surgery.

4. An antepartum client is Rh negative and understands that she will receive a RhoGAM injection during her pregnancy. The client asks the nurse if she will also receive a RhoGAM injection after the birth of her baby. The client will receive RhoGAM after the birth if blood tests are:

• A. Mother Rh positive; baby Rh negative
• B. Mother Rh negative; Coombs positive; baby Rh negative
• C. Mother Rh positive; Coombs negative; baby Rh positive
• D. Mother Rh negative; Coombs negative; baby Rh positive

Correct answer: D

Rationale: The correct answer is D. If the baby is Rh positive and the mother is Rh negative, the mother may develop antibodies against the baby's blood. RhoGAM is administered to prevent the mother's immune system from becoming sensitized to Rh-positive blood. Therefore, the mother, who is Rh negative, will receive RhoGAM after birth if the baby is Rh positive and both the mother and baby have negative Coombs tests. Choices A, B, and C are incorrect because they do not match the criteria for RhoGAM administration in this scenario.

5. A nurse is assessing a newborn and notes that the infant has yellow-tinged skin. Which of the following is the priority nursing action?

• A. Assess the infant's bilirubin levels
• B. Initiate phototherapy
• C. Monitor the infant's temperature
• D. Encourage breastfeeding

Correct answer: A

Rationale: Yellow-tinged skin (jaundice) in a newborn can indicate hyperbilirubinemia. The priority action is to assess the infant's bilirubin levels to determine the severity of the jaundice and the need for further interventions, such as phototherapy. Initiating phototherapy (choice B) is premature without knowing the actual bilirubin levels. Monitoring the infant's temperature (choice C) is important but not the priority in this situation. Encouraging breastfeeding (choice D) is beneficial but not the priority when dealing with jaundice in a newborn.

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