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 is grieving the loss of her partner and expresses thoughts of not seeing the point of living anymore. What action should the nurse take?

• A. Recommend that the client seek spiritual guidance
• B. Request additional support from the client's family
• C. Tell the client that this is a normal response to grief
• D. Ask the client if she plans to harm herself

Correct answer: D

Rationale: When a client expresses feelings of hopelessness or worthlessness, it is crucial for the nurse to assess for suicidal ideation. Asking the client directly if she plans to harm herself is essential to determine the level of risk and ensure appropriate interventions are implemented. Recommending spiritual guidance (Choice A) may not address the immediate safety concerns related to suicidal ideation. Requesting additional support from the client's family (Choice B) is not as direct in addressing the client's safety. While stating that the client's response is a normal part of grief (Choice C) may provide validation, it does not address the potential risk of harm to the client.

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. A healthcare professional is planning care for a female client who has an indwelling urinary catheter. Which of the following actions should the healthcare professional include in the plan?

• A. Empty the drainage bag at least every 8 hours
• B. Keep the drainage bag below the level of the bladder
• C. Use sterile technique to collect a specimen from the drainage system
• D. Secure the catheter to the lower abdomen with a securement device

Correct answer: B

Rationale: The correct action to include in the plan is to keep the drainage bag below the level of the bladder. This positioning helps ensure proper drainage and prevents backflow of urine into the bladder, reducing the risk of urinary tract infections. Emptying the drainage bag regularly is important, typically every 4-8 hours or when it is half-full, to maintain adequate flow and prevent infection (Choice A is incorrect). Using a sterile technique to collect specimens from the drainage system is crucial to prevent introducing pathogens into the urinary tract, so clean technique should not be used (Choice C is incorrect). Taping the catheter to the lower abdomen is not recommended as it can cause tension on the catheter, leading to discomfort and potential trauma to the urethra (Choice D is incorrect).

5. Nurse talking with a client’s partner. She is having frustrations about managing responsibilities and care. What type of role performance stress is this?

• A. Role overload
• B. Role conflict
• C. Role ambiguity
• D. Role strain

Correct answer: A

Rationale: Role overload occurs when a person feels overwhelmed by the demands placed upon them.

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