Nursing Elites

1. The home health nurse suspects elder abuse after observing fresh lacerations on the arms and legs of an older adult male client who lives with his daughter. Which action is most important for the nurse to take?

• A. Document the lacerations in the client's record
• B. Report findings to the supervisor for referral to adult protective services
• C. Ask the daughter who has been taking care of the client on a daily basis
• D. Apply dry dressings after cleansing the wounds

Correct answer: B

Rationale: In cases where elder abuse is suspected, the most critical action for the nurse to take is to report the findings to the supervisor for referral to adult protective services. This step is essential to protect the client from further harm and ensure their safety. Documenting the lacerations, as suggested in choice A, is important but not as urgent as ensuring immediate intervention by reporting the abuse. Asking the daughter for information, as in choice C, may not be effective if she is the abuser. Applying dressings, as in choice D, is a lower priority compared to taking action to address the suspected abuse.

2. Which task could the nurse safely delegate to the UAP?

• A. Oral feeding of a two-year-old child after application of a hip spica cast
• B. Assessment of the placement and patency of an NG tube
• C. Participation in staff rounds to record notes regarding client goals
• D. Evaluation of a client's incisional pain following narcotic administration

Correct answer: A

Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.

3. Which information should the nurse collect during the admission assessment of a terminally ill client to an acute care facility?

• A. Name of funeral home to contact
• B. Client's wishes regarding organ donation
• C. Contact information for the client's next of kin
• D. Healthcare proxy information

Correct answer: B

Rationale: During the admission assessment of a terminally ill client, it is crucial for the nurse to collect the client's wishes regarding organ donation. This information is vital to ensure that the care provided aligns with the client's values and preferences. Option A, 'Name of funeral home to contact,' is not a priority during the admission assessment and can be addressed later. Option C, 'Contact information for the client's next of kin,' is important but not as critical as understanding the client's wishes regarding organ donation. Option D, 'Healthcare proxy information,' is important for decision-making if the client is unable to make healthcare decisions, but knowing the client's wishes regarding organ donation takes precedence in this scenario.

4. The practical nurse is caring for a client whose urine drug screen is positive for cocaine. Which behavior is this client likely to exhibit during cocaine withdrawal?

• A. Elevated energy level
• B. Euphoria
• C. High self-esteem
• D. Powerful craving for more

Correct answer: D

Rationale: The correct answer is D: Powerful craving for more. During cocaine withdrawal, individuals often experience intense cravings for the drug, along with symptoms such as fatigue, depression, and anxiety. These cravings can be overpowering and lead to a strong desire to seek out more cocaine to alleviate the withdrawal symptoms. Choices A, B, and C are incorrect as elevated energy level, euphoria, and high self-esteem are more associated with the effects of cocaine rather than withdrawal symptoms. Withdrawal from cocaine is characterized by the opposite, such as fatigue, low mood, and intense cravings.

5. A post-operative client develops a sudden onset of chest pain and dyspnea. The nurse suspects a pulmonary embolism (PE). What is the priority nursing action?

• A. Administer oxygen via face mask.
• B. Elevate the client's legs.
• C. Prepare the client for immediate surgery.
• D. Notify the healthcare provider immediately.

Correct answer: A

Rationale: Administering oxygen via face mask is the priority nursing action in a post-operative client suspected of a pulmonary embolism. This intervention helps ensure adequate oxygenation while further assessments and interventions are initiated. Elevating the client's legs is not indicated for a suspected pulmonary embolism; it is more appropriate for conditions like shock. Immediate surgery is not the priority in this situation as the client is experiencing acute symptoms requiring prompt intervention. While notifying the healthcare provider is important, the immediate focus should be on providing oxygen to the client to support respiratory function.

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