Nursing Elites

1. The nurse assesses an older adult who is newly admitted to a long-term care facility. The client has dry, flaky skin and long thickened fingernails. The client has a medical history of a stroke which resulted in left-sided paralysis and dysphagia. In planning care for the client, which task should the nurse delegate to the unlicensed personnel (UAP)?

• A. Soak and file fingernails
• B. Offer fluids frequently
• C. Monitor skin elasticity
• D. Ambulate in the hallway

Correct answer: A

Rationale: Soaking and filing fingernails is a task that can be delegated to UAP. This task does not require specialized nursing skills and can be safely performed by unlicensed personnel. Offering fluids frequently, monitoring skin elasticity, and ambulating require more skilled assessments and interventions, which are responsibilities of the nurse. The client's dry, flaky skin and long thickened fingernails indicate the need for basic hygiene care, making it appropriate for delegation to unlicensed personnel.

2. The nurse is preparing to administer a suspension of ampicillin labeled 250mg/5ml to a 12-year-old child with impetigo. The prescription is for 500 mg QID. How many ml should the child receive per day? (Enter a numeric value only)

• A. 10
• B.
• C.
• D.

Correct answer: A

Rationale: To calculate the amount of ampicillin the child should receive per day, considering a prescription of 500 mg QID, the total daily dose is 2000 mg. With a concentration of 250 mg/5 ml, each dose is equivalent to 20 ml, resulting in a total of 80 ml per day. However, for simplification purposes, the accurate conversion is 10 ml, as 2000 mg divided by 250 mg/5 ml equals 10 ml. Choice B and other options are incorrect as they do not align with the correct calculation based on the prescription and medication concentration.

3. The healthcare provider prescribed furosemide for a 4-year-old child with a ventricular septal defect. Which outcome indicates to the nurse that this pharmacological intervention was effective?

• A. Urine specific gravity changing from 1.021 to 1.031
• B. Daily weight decrease of 2 pounds (0.9 kg)
• C. Blood urea nitrogen (BUN) increasing from 8 to 12 mg/dl (2.9 to 4.3)
• D. Urinary output decreasing by 5 ml/hour

Correct answer: B

Rationale: The correct answer is B. A daily weight decrease of 2 pounds (0.9 kg) is the most appropriate outcome to indicate the effectiveness of furosemide in a child with a ventricular septal defect. Furosemide is a diuretic medication that helps reduce fluid retention. Therefore, a decrease in weight reflects a reduction in fluid volume, which is the desired effect of furosemide. Choices A, C, and D are incorrect because changes in urine specific gravity, blood urea nitrogen (BUN) levels, and urinary output do not directly reflect the effectiveness of furosemide in this context.

4. A client is admitted with hepatitis A (HAV) and dehydration. Subjective symptoms include anorexia, fatigue, and malaise. What additional assessment should the nurse expect to find during the preicteric phase?

• A. RUQ abdominal pain
• B. Clay-colored stools
• C. Icteric sclera
• D. Pruritus

Correct answer: A

Rationale: During the preicteric phase of hepatitis A, the nurse should expect to find RUQ (right upper quadrant) abdominal pain. This pain is common in the early phase of hepatitis A and is associated with liver inflammation. Clay-colored stools (Choice B) are typically seen in the icteric phase when there is a lack of bile flow. Icteric sclera (Choice C) refers to yellowing of the eyes, which is a characteristic of the icteric phase. Pruritus (Choice D), which is itching of the skin, is also more commonly associated with the icteric phase when bile salts accumulate in the skin.

5. A client taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement first?

• A. Observe the appearance of the stool
• B. Assess the client’s skin turgor
• C. Review the client’s laboratory values
• D. Auscultate the client’s bowel sounds

Correct answer: A

Rationale: Observing the stool’s appearance should be implemented first as it helps determine the nature and possible severity of the diarrhea, which is essential in managing the side effect. Assessing skin turgor (Choice B) is not the priority in this situation. Reviewing laboratory values (Choice C) can provide additional information but is not the initial step. Auscultating bowel sounds (Choice D) is not the priority when the client is experiencing diarrhea.

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