Nursing Elites

1. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client's blood pressure is much higher than previous readings & the client's mental status has changed. What action by the nurse would most likely have prevented this negative outcome?

• A. Determining if the UAP knew how to take blood pressure
• B. Double-checking the UAP by taking another blood pressure
• C. Providing more appropriate supervision of the UAP
• D. Taking the blood pressure instead of delegating the task

Correct answer: C

Rationale: The most likely action by the nurse that would have prevented the negative outcome is providing more appropriate supervision of the UAP. Supervision is essential in delegation as it involves directing, evaluating, and following up on delegated tasks. By providing adequate supervision, the nurse can ensure that tasks are performed correctly and promptly identify any issues or abnormalities, such as a significant change in vital signs or the client's mental status. This proactive approach can help prevent adverse outcomes and enhance patient safety.

2. A client developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

• A. Decreased serum calcium level
• B. Decreased level of serum lipids
• C. Decreased erythrocyte sedimentation rate (ESR)
• D. Increased platelet count

Correct answer: A

Rationale: In fat embolism syndrome (FES), fat globules enter the bloodstream and can lead to various complications, including a decrease in serum calcium levels. This occurs due to the formation of fat emboli in the vessels, which can interfere with calcium metabolism. Therefore, a decreased serum calcium level is an expected laboratory finding in a client with fat embolism syndrome.

3. During an assessment, a client with a long history of smoking and suspected laryngeal cancer will most likely report which early manifestation?

• A. Dysphagia
• B. Hoarseness
• C. Dyspnea
• D. Weight loss

Correct answer: B

Rationale: In clients with laryngeal cancer, hoarseness is often one of the earliest manifestations due to vocal cord involvement. The irritation and inflammation caused by the tumor affect the vocal cords, leading to changes in voice quality. Dysphagia (choice A) typically occurs later as the tumor grows and interferes with swallowing. Dyspnea (choice C) and weight loss (choice D) may occur as the cancer progresses, but hoarseness is usually among the first signs to manifest in laryngeal cancer.

4. After auscultating a client's breath sounds, the nurse is providing care. Which finding is correctly matched to the nurse's primary intervention?

• A. Hollow sounds are heard over the trachea. The nurse increases the oxygen flow rate.
• B. Crackles are heard in bases. The nurse encourages the client to cough forcefully.
• C. Wheezes are heard in central areas. The nurse administers an inhaled bronchodilator.
• D. Vesicular sounds are heard over the periphery. The nurse has the client breathe deeply.

Correct answer: C

Rationale: Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages, making option C the correct match. Wheezes are typically heard in the central or peripheral lung areas and are associated with conditions like asthma or COPD. Inhaled bronchodilators work by dilating the bronchioles, which helps alleviate wheezing and improve airflow. Therefore, administering an inhaled bronchodilator is the appropriate intervention in response to wheezes.

5. A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select ONE that does not apply)

• A. Production of pink sputum
• B. Tracheal deviation
• C. Pain at insertion site
• D. Sudden onset of shortness of breath

Correct answer: A

Rationale: In a client with a mediastinal chest tube, the presence of pink sputum does not necessarily require immediate intervention. However, tracheal deviation could indicate a tension pneumothorax, sudden shortness of breath could signal tube issues or pneumothorax, and drainage exceeding 70 mL/hr might suggest hemorrhage. Disconnection at the Y site could lead to air entering the tubing, necessitating prompt attention.

Similar Questions