Nursing Elites

1. In preparing assignments for the shift, which client is best for the charge nurse to assign to a practical nurse (PN)?

• A. An older client who fell yesterday and is now complaining of diplopia.
• B. An adult newly diagnosed with type 1 diabetes and high cholesterol.
• C. A client with pancreatic cancer who is experiencing intractable pain.
• D. An older client post-stroke who is aphasic with right-sided hemiplegia.

Correct answer: D

Rationale: The best client for the charge nurse to assign to a practical nurse (PN) is an older client post-stroke who is aphasic with right-sided hemiplegia. This client is stable and suitable for care by a PN under supervision. Choices A, B, and C present clients with more complex and acute conditions that would require a higher level of nursing expertise and intervention.

2. The nurse is caring for a client with a chest tube in place following a pneumothorax. Which assessment finding requires immediate intervention?

• A. Oxygen saturation of 94%
• B. Crepitus around the insertion site
• C. Subcutaneous emphysema
• D. Blood pressure of 110/70 mmHg

Correct answer: C

Rationale: Subcutaneous emphysema is the assessment finding that requires immediate intervention in a client with a chest tube following a pneumothorax. Subcutaneous emphysema can indicate a pneumothorax recurrence or air leak, which can compromise respiratory function and lead to serious complications. Oxygen saturation of 94% may be concerning but does not require immediate intervention as it is still within an acceptable range. Crepitus around the insertion site is common after chest tube placement and may not always indicate a problem. A blood pressure of 110/70 mmHg is within normal limits and does not require immediate intervention in this context.

3. The nurse observes an unlicensed assistive personnel (UAP) positioning a newly admitted client who has a seizure disorder. The client is supine, and the UAP is placing soft pillows along the side rails. What action should the nurse take?

• A. Ensure that the UAP has positioned the pillows effectively to protect the client.
• B. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows.
• C. Assume responsibility for placing the pillows while the UAP completes another task.
• D. Ask the UAP to use some of the pillows to prop the client in a side-lying position.

Correct answer: B

Rationale: The nurse should instruct the UAP to pad the side rails with soft blankets instead of pillows. Placing pillows along the side rails could lead to suffocation during a seizure and would need to be removed promptly. Instructing the UAP to use soft blankets is safer as they can help prevent injury without posing a risk of suffocation. Ensuring effective placement of the pillows (Choice A) is not appropriate as pillows should not be used in this situation. Assuming responsibility for placing the pillows (Choice C) or propping the client in a side-lying position with pillows (Choice D) are both unsafe actions and could potentially harm the client.

4. The nurse is planning care for a client admitted with a diagnosis of pheochromocytoma. Which intervention has the highest priority for inclusion in this client's plan of care?

• A. Record urine output every hour
• B. Monitor blood pressure frequently
• C. Evaluate neurological status
• D. Maintain seizure precautions

Correct answer: B

Rationale: Monitoring blood pressure frequently is the highest priority intervention for a client diagnosed with pheochromocytoma. This rare tumor can lead to life-threatening hypertension due to catecholamine secretion. Evaluating neurological status and maintaining seizure precautions are important but are not the highest priority in this case. Recording urine output, though essential for overall assessment, is not the priority compared to monitoring blood pressure in a client with pheochromocytoma.

5. A newly graduated female staff nurse requests reassignment to another client because a male client is asking her for a date and making suggestive comments. Which response is best for the nurse manager to provide?

• A. I have to call the supervisor to get someone else to transfer to this unit to care for him.
• B. I know you are a good nurse and can handle this client in a professional manner.
• C. I'll talk to the client about his behavior and insist that he stop it immediately.
• D. I'll change your assignment, but let's talk about how a nurse should respond to this kind of client.

Correct answer: D

Rationale: The best response for the nurse manager to provide in this situation is option D, which involves changing the assignment to address the nurse's immediate concern. It also offers an opportunity to have a conversation with the nurse about how to professionally handle such situations in the future. Option A is not the best response as it does not address the underlying issue and simply shifts the problem to another staff member. Option B, while supportive, does not actively address the client's inappropriate behavior. Option C is not ideal as the nurse manager should handle discussions about inappropriate behavior with clients themselves rather than delegating it to the staff nurse.

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