Nursing Elites

1. A patient requires repositioning every 2 hours. Which task can the nurse delegate to the nursing assistive personnel?

• A. Determining the level of comfort
• B. Changing the patient's position
• C. Identifying immobility hazards
• D. Assessing circulation

Correct answer: B

Rationale: The correct answer is B: 'Changing the patient's position.' Repositioning the patient involves physically moving and adjusting their position in bed, which is a task that can be safely delegated to nursing assistive personnel (NAP). This task does not require clinical judgment or assessment skills beyond the ability to follow guidelines for proper positioning. Choices A, C, and D involve assessments or judgments that require a higher level of training and knowledge, making them more appropriate for a nurse to perform. Choice A involves assessing comfort, which may involve subjective factors and individual preferences. Choice C involves identifying hazards related to immobility, which requires understanding the potential risks and complications associated with immobility. Choice D involves assessing circulation, which requires a higher level of clinical knowledge and understanding of circulatory issues.

2. A client reports constipation, and a nurse is providing dietary teaching. Which of the following foods should the nurse recommend?

• A. Macaroni and cheese
• B. One medium apple with skin
• C. One cup of plain yogurt
• D. Roast chicken and white rice

Correct answer: B

Rationale: The correct answer is B: One medium apple with skin. Foods high in fiber, like apples with skin, are recommended to relieve constipation due to their fiber content, which aids in bowel regularity. Macaroni and cheese, yogurt, and roast chicken with white rice do not provide as much fiber and are less effective in alleviating constipation. While yogurt can sometimes contain probiotics that support gut health, it is not as effective in treating constipation as high-fiber foods like apples.

3. A client has been coughing for 3 weeks and is beginning to cough up blood. The client has manifestations of which of the following conditions?

• A. Allergic reaction
• B. Ringworm
• C. Systemic lupus erythematosus
• D. Tuberculosis

Correct answer: D

Rationale: The correct answer is D: Tuberculosis. Coughing up blood (hemoptysis) is a key symptom of tuberculosis. Tuberculosis is a respiratory infection caused by the bacterium Mycobacterium tuberculosis. The other options are incorrect because an allergic reaction typically involves symptoms like itching, hives, or swelling, not coughing up blood. Ringworm is a fungal skin infection characterized by a red, circular rash, and systemic lupus erythematosus is an autoimmune disease that primarily affects joints and skin without causing hemoptysis.

4. During a skin assessment, a healthcare professional is observing a group of clients. Which of the following lesions should the healthcare professional identify as vesicles?

• A. Acne
• B. Warts
• C. Psoriasis
• D. Herpes simplex

Correct answer: D

Rationale: Vesicles are small fluid-filled blisters. Herpes simplex is an example of a vesicular lesion, characterized by small, fluid-filled blisters. Acne presents as comedones, papules, pustules, or nodules, not vesicles. Warts are caused by the human papillomavirus and appear as rough, raised growths. Psoriasis is a chronic autoimmune condition that results in red, scaly patches on the skin, not vesicles.

5. A client with Guillain-Barre syndrome is in a non-responsive state, yet vital signs are stable and breathing is independent. What should the nurse document to most accurately describe the client's condition?

• A. Comatose, breathing unlabored
• B. Glascow Coma Scale 8, respirations regular
• C. Appears to be sleeping, vital signs stable
• D. Glascow Coma Scale 13, no ventilator required

Correct answer: B

Rationale: The correct answer is B. When documenting a client in a non-responsive state with stable vital signs and independent breathing, the nurse should document the Glasgow Coma Scale score to assess the level of consciousness and the regularity of respirations. Choice A is incorrect because 'comatose' implies a deeper level of unconsciousness than described in the scenario. Choice C is incorrect as it does not provide a specific assessment like the Glasgow Coma Scale score. Choice D is incorrect as a Glasgow Coma Scale score of 13 indicates a more alert state than described in the scenario.

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