Nursing Elites

1. The nurse is caring for a client post-surgery with an order to ambulate the client every 2 hours. Which of the following tasks could be safely delegated to an unlicensed assistive personnel (UAP)?

• A. Assessing the client's ability to ambulate safely
• B. Documenting the client's tolerance of ambulation
• C. Assisting the client with ambulation
• D. Evaluating the client's pain level after ambulation

Correct answer: C

Rationale: Assisting with ambulation is a task that can be safely delegated to a UAP as it is a supportive activity that does not require clinical judgment. Choices A, B, and D involve assessments, documentation, and evaluation, which require nursing knowledge and clinical judgment, making them tasks that should be performed by a licensed nurse.

2. A client with a urinary tract infection is prescribed ciprofloxacin. What is the nurse's priority teaching?

• A. Take the medication with a full glass of water.
• B. Avoid direct sunlight while taking the medication.
• C. Take the medication with meals to prevent nausea.
• D. Discontinue the medication if you experience dizziness.

Correct answer: A

Rationale: The correct answer is A: 'Take the medication with a full glass of water.' It is crucial for the nurse to teach the client to take ciprofloxacin with a full glass of water to prevent crystalluria, a potential side effect of the medication. Choice B is incorrect because ciprofloxacin does not require avoiding direct sunlight. Choice C is incorrect as taking the medication with meals is not necessary to prevent nausea. Choice D is incorrect as dizziness is not a common reason to discontinue ciprofloxacin.

3. A client reports that the skin around the edges of a wound is red and swollen. What is the nurse's priority intervention?

• A. Monitor for signs of infection
• B. Reinforce the wound dressing
• C. Contact the healthcare provider
• D. Apply a warm compress to the wound

Correct answer: A

Rationale: The correct answer is to monitor for signs of infection. Redness and swelling around a wound are indicative of a potential infection. The priority intervention for the nurse is to closely monitor the wound for further signs of infection, such as increased drainage or fever. Reinforcing the wound dressing may be necessary, but it is not the priority when infection is suspected. Contacting the healthcare provider is important, but the nurse should first assess and monitor the wound to provide comprehensive information when contacting the provider. Applying a warm compress can potentially worsen the infection by promoting bacterial growth, so it is contraindicated in this situation.

4. A female client taking prednisone reports feeling tired after stopping the corticosteroid abruptly. What is the priority nursing intervention?

• A. Auscultate breath sounds.
• B. Measure vital signs.
• C. Palpate the abdomen.
• D. Observe the skin for bruising.

Correct answer: C

Rationale: The correct answer is to palpate the abdomen. When a client abruptly stops taking prednisone, there is a risk of adrenal insufficiency, which can present with symptoms like fatigue. Palpating the abdomen is crucial to assess for signs of adrenal crisis, such as abdominal pain, which can indicate severe adrenal insufficiency. Auscultating breath sounds (Choice A) and observing the skin for bruising (Choice D) are not the priority interventions in this situation. While measuring vital signs (Choice B) is important, palpating the abdomen takes precedence in this case to assess for potential adrenal insufficiency.

5. At 0600 while admitting a woman for a scheduled repeat cesarean section, the client tells the nurse that she drank a cup of coffee at 0400 because she wanted to avoid getting a headache. Which action should the nurse take first?

• A. Cancel the surgery
• B. Inform the anesthesia care provider
• C. Ask the client if she has had any other liquids
• D. Proceed with routine preparations

Correct answer: B

Rationale: Drinking liquids before surgery can increase the risk of aspiration during anesthesia. Therefore, the anesthesia care provider must be informed immediately to determine how to proceed, as this could delay or alter the surgical plan. Canceling the surgery without consulting the anesthesia care provider would be premature and could potentially lead to unnecessary actions. Asking the client if she has had any other liquids is important but not the first priority. Proceeding with routine preparations without addressing the potential issue of ingesting liquids before surgery could compromise the client's safety.

Similar Questions