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 client is in the transition phase of labor. Which of the following actions should the nurse take?

• A. Assist the client to void every 3 hours
• B. Monitor contractions every 30 minutes
• C. Place the client in a lithotomy position
• D. Encourage the client to use a pant-blow breathing pattern

Correct answer: D

Rationale: Encouraging the client to use a pant-blow breathing pattern is crucial during the transition phase of labor. This phase is characterized by intense contractions and emotional responses. Pant-blow breathing helps manage pain and anxiety, providing comfort and support to the client. Voiding every 3 hours is not specific to the transition phase and may not address immediate needs. Monitoring contractions every 30 minutes is important but may not be as directly beneficial as focusing on coping mechanisms like breathing techniques. Placing the client in a lithotomy position is generally not recommended during the transition phase as it can impede progress and comfort.

3. A client with mild persistent asthma is being taught about montelukast by a nurse. Which statement by the client indicates understanding?

• A. I will use this for asthma attacks.
• B. I should take this before exercise.
• C. This medication will decrease swelling and mucus production.
• D. I can stop this medication after 10 days.

Correct answer: C

Rationale: The correct answer is C: 'This medication will decrease swelling and mucus production.' Montelukast is a leukotriene receptor antagonist that works by reducing swelling and mucus production in the airways, helping to manage asthma symptoms in the long term. Choices A, B, and D are incorrect because montelukast is not used for immediate relief during asthma attacks, pre-exercise prophylaxis, or short-term treatment; instead, it is taken regularly for asthma control.

4. A healthcare professional is preparing to administer a dose of nitroglycerin. Which of the following should be assessed first?

• A. Blood pressure
• B. Heart rate
• C. Pain level
• D. Respiratory rate

Correct answer: A

Rationale: The correct answer is to assess blood pressure first before administering nitroglycerin. Nitroglycerin is a vasodilator that can cause a sudden drop in blood pressure, leading to adverse effects such as dizziness or fainting. Assessing blood pressure before administration helps determine if the patient's blood pressure is within the acceptable range for nitroglycerin administration. Heart rate, pain level, and respiratory rate are also important assessments, but blood pressure should take precedence due to the vasodilating effects of nitroglycerin.

5. A healthcare provider is preparing to administer an influenza vaccine to an adult client. Which of the following is a contraindication?

• A. Client has a low-grade fever
• B. Client is allergic to eggs
• C. Client had recent surgery
• D. Client is on corticosteroid therapy

Correct answer: B

Rationale: The correct answer is B: Client is allergic to eggs. The influenza vaccine is contraindicated in individuals with an allergy to eggs because some influenza vaccines are produced using egg-based processes. Choices A, C, and D are not contraindications for administering the influenza vaccine. A low-grade fever, recent surgery, and corticosteroid therapy are not contraindications for receiving the influenza vaccine.

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