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. 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.

3. A client with cirrhosis is experiencing pruritus. Which intervention should the nurse include in the care plan?

• A. Administer antihistamines as prescribed
• B. Apply alcohol-based lotions to the skin
• C. Encourage frequent baths with hot water
• D. Limit fluid intake

Correct answer: A

Rationale: The correct answer is A: Administer antihistamines as prescribed. Pruritus, or itching, is a common symptom in clients with cirrhosis. Antihistamines can help relieve itching by blocking the effects of histamine. Applying alcohol-based lotions (choice B) can further dry out the skin and exacerbate itching. Encouraging frequent baths with hot water (choice C) can also worsen pruritus by stripping the skin of natural oils. Limiting fluid intake (choice D) is not directly related to managing pruritus in cirrhosis.

4. A client is prescribed warfarin for the prevention of thromboembolism. What dietary instruction should the nurse provide?

• A. Increase intake of green leafy vegetables
• B. Maintain a consistent intake of vitamin K-rich foods
• C. Avoid all foods containing vitamin K
• D. Consume a high-protein diet

Correct answer: B

Rationale: The correct answer is B. Maintaining a consistent intake of vitamin K-rich foods is important for patients taking warfarin as it helps keep the effects of the medication stable. Choice A is incorrect because while green leafy vegetables are high in vitamin K, they should not be avoided completely but rather consumed consistently. Choice C is also incorrect as avoiding all foods containing vitamin K can lead to fluctuations in warfarin's effectiveness. Choice D is incorrect as a high-protein diet is not specifically recommended for patients taking warfarin.

5. The nurse is preparing a client for discharge after a major surgical procedure. What is the priority instruction to include in the discharge teaching?

• A. Signs of infection to monitor for
• B. Pain management techniques
• C. Activity restrictions and safety measures
• D. All of the above

Correct answer: D

Rationale: The correct answer is D: All of the above. Providing comprehensive discharge instructions covering signs of infection to monitor for, pain management techniques, activity restrictions, and safety measures is crucial after a major surgical procedure. Each of these components plays a vital role in the client's recovery and well-being. It is important for the client to understand how to identify signs of infection, manage pain effectively, and adhere to activity restrictions to prevent complications and ensure a smooth recovery process. While each instruction is important on its own, combining all aspects into the discharge teaching ensures that the client has a holistic understanding of their post-operative care, empowering them to take charge of their health and know when to seek further assistance if needed. Choices A, B, and C are essential components of discharge teaching and should all be included to provide the client with comprehensive care instructions.

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