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. While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client's nose and mouth.

Correct answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

3. A client has a new prescription for parenteral nutrition (PN) in 20% dextrose and fat emulsions. Which of the following is an appropriate action to include in the plan of care?

• A. Monitor blood glucose levels daily.
• B. Change the PN infusion bag every 24 hours.
• C. Prepare the client for a central venous line.
• D. Administer the PN and fat emulsion together.

Correct answer: C

Rationale: When a client requires parenteral nutrition (PN) with a high dextrose concentration, such as 20%, it typically has a high osmolarity. High osmolarity solutions should be infused through a central venous line to prevent peripheral vein irritation and potential complications. Therefore, preparing the client for a central venous line is essential for the safe administration of PN with high dextrose. Monitoring blood glucose levels daily is important but not directly related to the need for a central venous line. Changing the PN infusion bag every 24 hours helps prevent bacterial contamination, but it is not the most critical action in this scenario. Administering the PN and fat emulsion together or separately is a matter of compatibility and administration guidelines, but it is not the key concern in this situation.

4. In an emergency situation, the charge nurse on the night shift at an urgent care center has to deal with admitting clients of higher acuity than usual due to a large fire in the area. Which style of leadership and decision-making would be best in this circumstance?

• A. Assume a decision-making role
• B. Seek input from staff
• C. Use a non-directive approach
• D. Shared decision-making with others

Correct answer: A

Rationale: In an emergency situation such as dealing with patients of higher acuity due to a large fire, it is crucial for the charge nurse to assume a decision-making role. This style of leadership allows for quick and efficient decision-making to manage the increased acuity of patients effectively. Seeking input from staff (Choice B) may delay critical decisions needed in emergencies. Using a non-directive approach (Choice C) or shared decision-making with others (Choice D) may not be suitable in urgent situations where immediate actions are required to address the high acuity of patients.

5. When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next?

• A. Determine if the expected outcomes were realistic
• B. Obtain current client data to compare with expected outcomes
• C. Modify the nursing interventions to achieve the client's goals
• D. Review related professional standards of care

Correct answer: B

Rationale: After reviewing the expected outcomes in the plan of care, the nurse should obtain current client data to compare with these outcomes. This step is crucial in determining the effectiveness of the care provided. Choice A is incorrect because determining the realism of expected outcomes comes after assessing current client data. Choice C is incorrect as modifying nursing interventions should be based on the data comparison rather than done immediately after reviewing expected outcomes. Choice D is also incorrect as reviewing professional standards of care is important but not the immediate next step in evaluating care effectiveness.

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