Nursing Elites

1. The nurse assigns an unlicensed assistive personnel (UAP) to feed a client who is at risk for aspiration. What action should the nurse take to ensure safety?

• A. Inform the UAP that suction is available at the bedside.
• B. Instruct the UAP to notify the nurse if the client chokes.
• C. Observe the UAP's ability to implement precautions during feeding.
• D. Ask the UAP about previous experience in performing this skill.

Correct answer: C

Rationale: Observing the UAP's ability to implement precautions during feeding is crucial to ensuring the client's safety, especially when there is a risk of aspiration. This hands-on observation allows the nurse to assess whether the UAP is competent in handling the feeding procedure safely. Informing the UAP about suction availability (Choice A) is important but does not directly assess the UAP's ability during feeding. Instructing the UAP to notify the nurse if the client chokes (Choice B) focuses on reactive measures rather than proactive supervision. Asking about previous experience (Choice D) does not provide real-time information on the UAP's current competency in handling the specific feeding task for the at-risk client.

2. The nurse is caring for a client with a history of seizure disorder who is receiving phenytoin (Dilantin). Which laboratory value is most important to monitor?

• A. Phenytoin level
• B. Sodium level
• C. Hemoglobin level
• D. White blood cell count

Correct answer: A

Rationale: Corrected Rationale: Monitoring the phenytoin level is crucial to ensure it is within the therapeutic range and to prevent toxicity. Monitoring sodium level is important in clients receiving lithium, not phenytoin. Hemoglobin level and white blood cell count are not directly related to phenytoin therapy monitoring.

3. A client with a diagnosis of tuberculosis (TB) is being discharged home. Which instruction is most important for the nurse to provide?

• A. Avoid close contact with others until treatment is complete.
• B. Take all prescribed medications as directed.
• C. Schedule a follow-up appointment with the healthcare provider.
• D. Wear a mask when in public places.

Correct answer: B

Rationale: The most important instruction for a client with tuberculosis (TB) is to take all prescribed medications as directed. This is crucial to prevent the development of drug-resistant TB. While avoiding close contact with others until treatment is complete (Choice A) is important to prevent the spread of TB, ensuring the client completes the prescribed medication regimen is the priority. Scheduling a follow-up appointment (Choice C) is important for monitoring but not as critical as medication adherence. Wearing a mask in public places (Choice D) can help reduce the spread of TB but is not as essential as taking medications as prescribed.

4. A client with a history of peptic ulcer disease (PUD) is prescribed omeprazole (Prilosec). What is the primary action of this medication?

• A. Neutralizes stomach acid
• B. Reduces gastric acid production
• C. Forms a protective barrier over ulcers
• D. Increases gastric mucus production

Correct answer: B

Rationale: The correct answer is B: Reduces gastric acid production. Omeprazole is a proton pump inhibitor that works by reducing gastric acid production, thereby helping to heal ulcers. While neutralizing stomach acid is associated with antacids, forming a protective barrier over ulcers is more characteristic of medications like sucralfate. The action described in choice D, increasing gastric mucus production, is not the primary mechanism of action of omeprazole in treating peptic ulcer disease.

5. A client with a severe peanut allergy accidentally ingested peanut-containing food and is experiencing anaphylaxis. What is the nurse's priority action?

• A. Administer an epinephrine injection
• B. Call for immediate medical help
• C. Monitor airway, breathing, and circulation
• D. All of the above

Correct answer: A

Rationale: The priority action for a client experiencing anaphylaxis due to a severe peanut allergy is to administer an epinephrine injection. Epinephrine is the first-line treatment for anaphylaxis as it can rapidly reverse the severe allergic reaction. While calling for immediate medical help is important, administering epinephrine takes precedence because it can be life-saving in this situation. Monitoring airway, breathing, and circulation is essential in managing anaphylaxis, but administering epinephrine is the priority action to halt the progression of the allergic reaction and stabilize the client's condition. Therefore, 'Administer an epinephrine injection' is the most critical initial intervention.

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