Nursing Elites

1. A 45-year-old client with type I diabetes is in need of support services upon discharge from a skilled rehabilitation unit. Which of the following services is an example of a skilled support service?

• A. shopping for groceries
• B. house cleaning
• C. transportation to physician's visits
• D. medication instruction

Correct answer: D

Rationale: The correct answer is 'medication instruction.' This service involves educating the client on how to properly take their medications, which requires a certain level of expertise and skill. Grocery shopping, house cleaning, and transportation to physician's visits are considered unskilled services as they do not involve specialized knowledge or training. In contrast, medication instruction is a skilled service that necessitates specific training to ensure the client's safety and adherence to their medication regimen.

2. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

• A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
• B. Assisting a client who is getting up to ambulate for the first time after surgery
• C. Providing oral care to an unconscious client who requires oral care
• D. Completing the preoperative checklist for a client scheduled for a liver biopsy

Correct answer: C

Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.

3. To ensure proper immobilization and increase client comfort when using a rigid splint, what should be done?

• A. Place the client on a stretcher before splinting.
• B. Place the client on a long spine board before splinting.
• C. Pad the spaces between the body part and the splint.
• D. Ensure that the splint conforms to the body curves.

Correct answer: C

Rationale: Correct. When using a rigid splint, it is essential to pad the spaces between the body part and the splint to ensure proper immobilization and increase client comfort. This padding helps prevent pressure points and ensures a proper fit of the splint without causing discomfort. Placing the client on a stretcher or a long spine board before splinting (choices A and B) may be necessary for transportation but does not directly relate to the proper use of a rigid splint. Ensuring that the splint conforms to the body curves (choice D) is important but not as crucial as padding the spaces to prevent discomfort and ensure proper immobilization.

4. To remove hard contact lenses from an unresponsive client, what should the nurse do?

• A. Gently irrigate the eye with an irrigating solution from the inner canthus outward
• B. Grasp the lens with a gentle pinching motion
• C. Don sterile gloves before attempting the procedure
• D. Ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens

Correct answer: D

Rationale: When removing hard contact lenses from an unresponsive client, the nurse should ensure that the lens is centered on the cornea before gently manipulating the lids to release the lens. This approach helps prevent scratching the cornea. Gently maneuvering the upper and lower eyelids assists in loosening the lens for easy removal. Options A, B, and C are incorrect because irrigating the eye, grasping the lens, or wearing sterile gloves are not recommended methods for removing hard contact lenses. It is crucial to handle the situation delicately to avoid causing harm or discomfort to the client.

5. A nurse is planning task assignments for the day. Which assignment is the least appropriate for the nursing assistant?

• A. Assisting a client with dysphagia in eating
• B. Ambulating a client with Parkinson's disease
• C. Providing hygiene to a client with dementia
• D. Assisting a client with an above-the-knee amputation in showering

Correct answer: A

Rationale: The least appropriate assignment for a nursing assistant would be assisting a client with dysphagia in eating. This task requires specialized skills and knowledge to prevent complications such as choking and aspiration. Ambulating a client with Parkinson's disease, providing hygiene to a client with dementia, and assisting a client with an above-the-knee amputation in showering are tasks that a nursing assistant can safely perform without significant risk of complications. Assisting a client with dysphagia in eating involves higher risks and requires specific training, making it the least appropriate choice for a nursing assistant.

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