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. A nurse is planning task assignments for the day. Which task should the nurse assign to the nursing assistant?

• A. Suctioning a client who requires periodic suctioning
• B. Assessing a client who has undergone an arteriogram and requires close monitoring
• C. Performing colostomy irrigation on a client with an ostomy
• D. Assisting a client who needs frequent ambulation with a walker

Correct answer: D

Rationale: When delegating tasks, a nurse must consider the staff member's education and competency level. Noninvasive tasks like helping a client ambulate with a walker are usually suitable for nursing assistants. Suctioning a client and colostomy irrigation are invasive procedures that require a licensed nurse's skills. Assessing a client post-arteriogram for any complications or changes in condition also necessitates the expertise of a licensed nurse. Therefore, the most appropriate task to assign to a nursing assistant is assisting a client who needs frequent ambulation with a walker.

3. While undergoing fetal heart monitoring, a pregnant Native-American woman requests that a medicine woman be present in the examination room. Which of the following is an appropriate response by the nurse?

• A. "I will assist you in arranging to have a medicine woman present."?
• B. "We do not allow medicine women in exam rooms."?
• C. "That does not make any difference in the outcome."?
• D. "It is old-fashioned to believe in that."?

Correct answer: A

Rationale: The correct response is to show cultural awareness and respect the client's request by offering assistance in arranging for the medicine woman to be present. This approach acknowledges the importance of cultural beliefs and practices in the client's care, fostering trust and cooperation. Choices B, C, and D are inappropriate as they dismiss or belittle the client's cultural beliefs, showing insensitivity and lack of respect, which can negatively impact the nurse-client relationship.

4. What is the purpose of the hydraulic lift (Hoyer lift)?

• A. To assist clients who have had orthopedic surgery.
• B. To assist clients who are unable to stand and extremely obese clients.
• C. To assist clients of all ages in a hospital setting.
• D. To assist clients with special needs.

Correct answer: B

Rationale: The purpose of the hydraulic lift, also known as the Hoyer lift, is to facilitate safe transfers for clients who cannot stand or are extremely obese. It is specifically designed for assisting clients who are unable to stand and for those who are too heavy for healthcare workers to lift safely. Choice A is incorrect because the primary purpose of a hydraulic lift is not related to orthopedic surgery. Choice C is incorrect because it is too broad and does not capture the specific use of the hydraulic lift. Choice D is incorrect because the lift is not solely for clients with special needs but rather for those who cannot stand or are extremely obese.

5. A nurse is performing suctioning through an adult client's tracheostomy tube. The nurse notes that the client's oxygen saturation is 89% and terminates the procedure. Which action would the nurse take next?

• A. Rechecking the pulse oximetry reading
• B. Calling the respiratory therapist
• C. Calling the healthcare provider
• D. Oxygenating the client with 100% oxygen

Correct answer: D

Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation to below 90% indicates hypoxemia. If hypoxia occurs during suctioning, the nurse must terminate the procedure and oxygenate the client with 100% oxygen to address the hypoxemia promptly and ensure the client's safety. Rechecking the pulse oximetry reading is important, but the priority is to address the hypoxemia by providing oxygen. Contacting the healthcare provider or respiratory therapist is not necessary at this time as the nurse can manage the hypoxemia with oxygenation. Oxygenating the client with 100% oxygen is the immediate action required in this situation.

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