Nursing Elites

1. Nail and foot care are essential in meeting the basic hygiene needs of clients. Important assessments by the nurse in this area include:

• A. a full-body assessment is not specific to nail and foot care.
• B. the essential lab work of the client is not related to nail and foot assessments.
• C. the nail beds and the tissue surrounding the nails.
• D. foot corns and calluses only neglect other important aspects of nail and foot care.

Correct answer: C

Rationale: The correct answer is to assess the nail beds and the tissue surrounding the nails. This assessment is crucial to identify abnormal discoloration, lesions, paronychia, dryness, breaks in the skin, pressure areas, or any other unusual appearances. Choice A is incorrect as a full-body assessment is broader and not specific to nail and foot care. Choice B is incorrect as lab work is not directly related to nail and foot assessments. Choice D is incorrect as it focuses only on foot corns and calluses, neglecting other important aspects of nail and foot care.

2. While assisting a healthcare provider in assessing a hospitalized client, the healthcare provider is paged to report to the recovery room. The healthcare provider instructs the nurse verbally to change the solution and rate of the intravenous (IV) fluid being administered. What is the most appropriate nursing action in this situation?

• A. Calling the nursing supervisor to obtain permission to accept the verbal prescription
• B. Asking the healthcare provider to write the prescription in the client's record before leaving the nursing unit
• C. Telling the healthcare provider that the prescription will not be implemented until it is documented in the client's record
• D. Changing the solution and rate of the IV fluid per the healthcare provider's verbal prescription

Correct answer: B

Rationale: Verbal prescriptions should be avoided due to the risk of errors. If a verbal prescription is necessary, it should be promptly written and signed by the healthcare provider, typically within 24 hours. Following agency policies and procedures regarding verbal prescriptions is crucial. In this scenario, the most appropriate nursing action is to request the healthcare provider to document the prescription in the client's record before leaving the unit. Calling the nursing supervisor to accept the verbal prescription without documentation, telling the healthcare provider to delay treatment until documented, and directly changing the IV fluid based on verbal orders all pose risks and do not align with best practices in medication administration.

3. Which is an appropriate outcome for the nursing diagnosis of Body Image Disturbance for a client with anorexia nervosa?

• A. The client verbalizes knowledge of a maintenance diet.
• B. The client demonstrates assertiveness with family.
• C. The client verbalizes her body size accurately.
• D. The client demonstrates control of obsessive behaviors.

Correct answer: C

Rationale: The correct answer is 'The client verbalizes her body size accurately.' For clients with anorexia nervosa, body image disturbance is a common issue where they perceive themselves inaccurately. Verbalizing her body size accurately indicates progress towards correcting this distorted self-perception. Choices A, B, and D are incorrect because they do not directly address the distorted body image perception seen in clients with anorexia nervosa. Choice A focuses on knowledge of a maintenance diet, which is unrelated to body image perception. Choice B involves assertiveness with family, which is more related to family dynamics. Choice D addresses control of obsessive behaviors, which is not directly related to correcting the distorted body image perception.

4. What is the term for the tendency of a drug to combine with its receptor?

• A. potency
• B. efficacy
• C. kinetics
• D. affinity

Correct answer: D

Rationale: The correct answer is 'affinity.' Affinity refers to the close relationship or mutual attraction between a drug and its receptor, indicating the strength of the drug-receptor bonding. Potency (Choice A) is related to the dose of a drug needed to produce a specific effect. Efficacy (Choice B) refers to a drug's ability to generate the desired effect. Kinetics (Choice C) deals with forces affecting the motion of material bodies or changes in a system, which is not directly associated with the bonding between a drug and its receptor.

5. A nurse is reviewing the notes written by a nurse on a previous shift. Which note in the client's record reflects the correct use of guidelines for documentation?

• A. The client's wound is healing well.
• B. The client seems anxious.
• C. The client's intake was 360 mL
• D. The client is voiding large amounts

Correct answer: C

Rationale: Quality documentation and reporting require information to be factual, accurate, complete, current, and organized. Choice C, 'The client's intake was 360 mL,' reflects the correct use of guidelines for documentation as it provides a specific and measurable observation. This note meets the criteria for quality documentation by being specific and quantifiable. Choices A, B, and D lack specificity and quantifiability. Choice A includes a subjective term 'well,' choice B uses 'seems' indicating uncertainty, and choice D uses a vague term 'large' without quantifying the amount.

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