Nursing Elites

1. The nurse is caring for a 69-year-old client with a diagnosis of hyperglycemia. Which tasks could the nurse delegate to the unlicensed assistive personnel (UAP)?

• A. Test blood sugar every 2 hours using Accu-Chek
• B. Review signs of hyperglycemia with the family and client
• C. Administer insulin if the blood sugar is elevated
• D. Measure the client's urine output

Correct answer: D

Rationale: The correct answer is D because measuring urine output is a task that falls within the UAP's scope of practice and does not require clinical decision-making. Choice A is incorrect because testing blood sugar using Accu-Chek involves interpreting results and possible adjustments, which require a licensed healthcare provider. Choice B is incorrect as discussing signs of hyperglycemia involves education and interpretation that should be done by a nurse. Choice C is incorrect since administering insulin is a high-risk task that necessitates precise dosing and monitoring, thus should not be delegated to UAP.

2. The nurse is caring for a client who had a myocardial infarction 6 hours ago. The primary goal of care at this time is to

• A. Limit the effects of tissue damage
• B. Relieve pain and anxiety
• C. Prevent arrhythmias
• D. Reduce anxiety

Correct answer: A

Rationale: The correct answer is A: 'Limit the effects of tissue damage.' After a myocardial infarction, the primary goal of care is to limit the damage to the heart muscle. This includes interventions to improve blood flow, oxygenation, and prevent further complications. Choice B ('Relieve pain and anxiety') is important but secondary to addressing tissue damage. Choice C ('Prevent arrhythmias') is also crucial but falls under the broader goal of limiting tissue damage. Choice D ('Reduce anxiety') is essential for holistic care but is not the primary goal immediately after a myocardial infarction.

3. A client with heart failure is experiencing shortness of breath and swelling in the legs. What is the nurse's priority intervention?

• A. Administer prescribed diuretics
• B. Place the client in a supine position
• C. Restrict fluid intake immediately
• D. Increase the client's sodium intake

Correct answer: A

Rationale: The correct answer is A: Administer prescribed diuretics. Diuretics are prescribed to reduce fluid overload in clients with heart failure. By promoting urine output, diuretics help alleviate symptoms like shortness of breath and swelling. While placing the client in a supine position can help with breathing and fluid redistribution, administering diuretics takes precedence as it directly addresses fluid overload. Restricting fluid intake immediately may be necessary in some cases, but the immediate priority is to administer diuretics. Increasing the client's sodium intake would worsen fluid retention and is contraindicated in heart failure.

4. Following a lumbar puncture, a client complains of worsening headache when sitting up. What complication is the client likely experiencing?

• A. A migraine headache
• B. An infection from the puncture site
• C. Low blood sugar
• D. Spinal fluid leakage (post-lumbar puncture headache)

Correct answer: D

Rationale: The client is likely experiencing spinal fluid leakage (post-lumbar puncture headache), a common complication of a lumbar puncture. This leakage results in a reduction of cerebrospinal fluid volume around the brain and spinal cord, leading to a headache that worsens when in an upright position due to reduced buoyancy. A migraine headache (Choice A) is not typically associated with a lumbar puncture. Infection from the puncture site (Choice B) would present with localized signs of inflammation, such as redness, swelling, and warmth, rather than worsening headache. Low blood sugar (Choice C) is not a common complication of lumbar puncture and would not typically manifest as a worsening headache when sitting up.

5. To auscultate for a carotid bruit, where should the nurse place the stethoscope?

• A. Base of the neck on the right side
• B. Above the clavicle
• C. Over the sternum
• D. Over the trachea

Correct answer: A

Rationale: To auscultate for a carotid bruit, the nurse should place the stethoscope at the base of the neck, near the carotid artery. A carotid bruit is an abnormal sound that indicates turbulent blood flow in the carotid artery, potentially due to arterial narrowing or atherosclerosis. Placing the stethoscope above the clavicle, over the sternum, or over the trachea would not provide the nurse with the optimal location to assess for carotid artery abnormalities.

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