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 healthcare professional is planning care to improve self-feeding for a client with vision loss. Which of the following interventions should the healthcare professional include in the plan of care?

• A. Instruct the client on the sequence of foods to eat first
• B. Offer small-handle utensils for the client to use
• C. Thicken liquids served to the client
• D. Use a clock pattern to indicate food placement on the client's plate

Correct answer: D

Rationale: The correct answer is D. When a client has vision loss, using a clock pattern to describe food placement on the plate can facilitate independent eating. This method enables the client to locate different food items based on their positions, enhancing self-feeding abilities. Instructing the client on the sequence of foods to eat first (Choice A) may not address the visual impairment directly. Providing small-handle utensils (Choice B) can be helpful for clients with limited dexterity but may not specifically assist a client with vision loss. Thickening liquids (Choice C) is more relevant for clients with dysphagia, not vision loss.

3. A client with cardiovascular disease is being taught by a nurse how to reduce sodium and cholesterol intake. The nurse understands that the most significant factor in planning dietary changes for this client is:

• A. Client’s financial resources
• B. Involvement of the client in planning the change
• C. Availability of low-sodium foods
• D. Frequency of dietary counseling sessions

Correct answer: B

Rationale: The most significant factor in planning dietary changes for a client with cardiovascular disease is the involvement of the client in planning the change. By involving the client in the planning process, the nurse ensures that the client takes ownership of their health and is more likely to adhere to and succeed in modifying dietary habits. This empowerment and engagement enhance the client's motivation and commitment to making sustainable changes. Financial resources, availability of low-sodium foods, and frequency of dietary counseling sessions are important considerations but are not as crucial as the client's active involvement in the planning process.

4. A young adult client is receiving instruction from a healthcare provider about health promotion and illness prevention. Which of the following statements indicates understanding?

• A. “I had my immunizations as a child, so I’m protected in that area.”
• B. “It is important to schedule routine health care visits even if I am feeling well.”
• C. “I will go to an urgent care center for my routine medical care.”
• D. “There’s no reason to seek help if I am feeling stressed as it’s just part of life.”

Correct answer: B

Rationale: The correct answer is B. Scheduling routine health care visits, even when feeling well, is crucial for early detection and prevention of health issues. This proactive approach allows healthcare providers to monitor overall health, provide preventive care, and address any emerging health concerns promptly. Choice A is incorrect because past immunizations do not cover all potential diseases; regular check-ups are still necessary. Choice C is incorrect as urgent care centers are not designed for routine medical care. Choice D is incorrect as seeking help for stress is important for mental well-being and should not be dismissed as a normal part of life.

5. A client who has just had a mastectomy has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device?

• A. Collapsing the device whenever it is 1/2 to 2/3 full of air.
• B. Emptying the device every 4 hours.
• C. Replacing the device every 24 hours.
• D. Keeping the device above the level of the surgical site.

Correct answer: A

Rationale: Collapsing the device when it is 1/2 to 2/3 full of air is the correct nursing action to ensure proper operation of a closed wound suction device (hemovac). This action maintains negative pressure, which is essential for proper suction and drainage of the wound. Emptying the device every 4 hours (Choice B) is not necessary as the focus should be on collapsing it appropriately. Replacing the device every 24 hours (Choice C) is not a standard practice unless indicated by the healthcare provider. Keeping the device above the level of the surgical site (Choice D) is not necessary for the device's proper operation; collapsing it to maintain negative pressure is the key action.

Similar Questions