Nursing Elites

1. The nurse has been assigned to train the unlicensed nursing assistant about prioritizing care. Which client should the nurse instruct the unlicensed nursing assistant to see first?

• A. The client who needs both sequential compression devices removed
• B. The elderly woman who needs assistance ambulating to the bathroom
• C. The surgical client who needs help changing the gown after bathing
• D. The male client who needs the intravenous fluid discontinued

Correct answer: A

Rationale: The correct answer is A because removing sequential compression devices could increase the risk of thromboembolism, making it the priority. Choice B involves assisting with ambulation, which can be done after addressing the urgent need of the client in choice A. Choice C and D involve non-urgent tasks compared to the potential risks associated with not removing sequential compression devices promptly.

2. Why may patients with hiatal hernia develop anemia?

• A. Iron absorption is reduced
• B. Gastritis may cause bleeding
• C. Iron stores turn over more quickly
• D. Patients have an aversion to foods that are good sources of iron

Correct answer: B

Rationale: The correct answer is B: Gastritis may cause bleeding. In patients with hiatal hernia, gastritis can lead to gastrointestinal bleeding, resulting in anemia due to blood loss. Choice A is incorrect because hiatal hernia does not directly affect iron absorption. Choice C is incorrect as iron stores turning over more quickly is not a typical reason for anemia in hiatal hernia patients. Choice D is incorrect as an aversion to iron-rich foods does not directly cause anemia in this context.

3. What is the most crucial and most difficult management skill required of the M6 practical nurse?

• A. Preparing time schedules and task assignment rosters
• B. Inspecting equipment for damage and proper function
• C. Preparing reports and maintaining records
• D. Effectively managing personnel

Correct answer: D

Rationale: The correct answer is D: Effectively managing personnel. In a healthcare setting, managing personnel is crucial as it involves leading, motivating, and coordinating the healthcare team to ensure quality patient care. While tasks like preparing schedules, inspecting equipment, and maintaining records are important, managing personnel involves dealing with human factors, conflicts, and emotions, making it the most challenging skill for a practical nurse.

4. Which outcome should the nurse identify for the client diagnosed with fluid volume excess?

• A. The client will void a minimum of 30 mL per hour
• B. The client will have elastic skin turgor
• C. The client will have no adventitious breath sounds
• D. The client will have a serum creatinine of 1.4 mg/dL

Correct answer: C

Rationale: The correct outcome for a client diagnosed with fluid volume excess is the absence of adventitious breath sounds. This indicates that fluid is not accumulating in the lungs, a crucial sign in managing fluid volume excess. Choices A, B, and D are incorrect because voiding a specific amount of urine, having elastic skin turgor, and a serum creatinine level do not directly relate to managing fluid volume excess.

5. Before administering an MMR (measles, mumps, and rubella) vaccine to a 15-month-old, which question should the nurse ask the mother of the child?

• A. “Has your child had any sore throats?”
• B. “Has your child been eating properly?”
• C. “Is your child allergic to any antibiotics?”
• D. “Has your child been exposed to any infections?”

Correct answer: C

Rationale: The correct question for the nurse to ask the mother before administering the MMR vaccine to a 15-month-old is about the child's allergy to antibiotics. This is crucial because the MMR vaccine contains neomycin, an antibiotic, and being allergic to antibiotics like neomycin is a contraindication for the MMR vaccine. Asking about sore throats, eating habits, or exposure to infections is not directly relevant to the administration of the MMR vaccine.

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