Nursing Elites

1. The nurse is caring for a patient diagnosed with diabetes. Which task will the nurse assign to the nursing assistive personnel?

• A. Providing nail care
• B. Teaching foot care
• C. Making the patient's bed
• D. Determining aspiration risk

Correct answer: C

Rationale: The correct answer is making the patient's bed. Delegating bed-making tasks to nursing assistive personnel is appropriate as it falls within their scope of practice and helps free up the nurse's time to focus on tasks that require their specialized skills and knowledge. Providing nail care and teaching foot care involve direct patient care and education, which should be performed by licensed nursing staff. Determining aspiration risk requires critical thinking and clinical judgment, making it a responsibility of the nurse.

2. A nurse is caring for a client postoperatively. When the nurse prepares to change the dressing, the client says it hurts. Which intervention is the nurse’s priority action?

• A. Administer pain medication 45 minutes prior to dressing change.
• B. Change the dressing quickly to minimize pain.
• C. Provide reassurance to the client that the pain will pass.
• D. Use a less painful dressing technique.

Correct answer: A

Rationale: Administering pain medication before the dressing change is the priority action to help manage the client's pain effectively. This intervention ensures that the client is comfortable during the procedure. Changing the dressing quickly may cause more discomfort to the client. Providing reassurance is important but does not address the immediate pain concern. Using a less painful dressing technique may be helpful, but administering pain medication first is the priority to address the client's pain promptly.

3. A healthcare professional is planning to perform ear irrigation on an adult client with impacted cerumen. Which of the following should the professional plan to take?

• A. Wearing sterile gloves while performing irrigation
• B. Positioning the client with the affected side down following irrigation
• C. Using cool fluid to irrigate the ear canal
• D. Pulling the pinna downward during irrigation

Correct answer: B

Rationale: Positioning the client with the affected side down following irrigation is crucial as it helps facilitate drainage of the dislodged cerumen and any remaining irrigation solution. This position allows gravity to assist in the removal of the loosened debris. Wearing sterile gloves is a standard precaution in healthcare procedures to prevent infection but is not specific to ear irrigation. Using body-temperature water or a solution at a slightly warmer temperature is recommended to prevent vertigo and discomfort, so using cool fluid is incorrect. Pulling the pinna upward and backward, not downward, straightens the ear canal for adults to facilitate the irrigation process, making choice D incorrect.

4. The healthcare provider is preparing to administer a subcutaneous injection of heparin. Which site is most appropriate for the healthcare provider to use?

• A. Deltoid muscle
• B. Ventrogluteal site
• C. Abdomen
• D. Dorsogluteal site

Correct answer: C

Rationale: The abdomen is the most appropriate site for administering subcutaneous heparin injections. The abdomen has a layer of subcutaneous fat and a good blood supply, making it an ideal site for subcutaneous injections. Using the deltoid muscle for heparin injections is not appropriate as it is typically used for intramuscular injections. The ventrogluteal site is more suitable for intramuscular injections rather than subcutaneous injections. The dorsogluteal site is no longer recommended for injections due to the risk of injury to the sciatic nerve.

5. A client with a terminal illness is being educated by a healthcare provider about her decision to decline resuscitation in her living will. The client asks about the scenario of having difficulty breathing upon arrival at the emergency department.

• A. “We will apply oxygen through a tube in your nose.”
• B. “We will perform resuscitation efforts regardless of your wishes.”
• C. “You will receive only palliative care.”
• D. “We will ensure your comfort measures are met as per your advance directives.”

Correct answer: A

Rationale: Choice A is correct because applying oxygen through a tube in the nose provides comfort and aligns with the client's wishes for palliative care without resuscitation. This intervention can help alleviate breathing difficulties and maintain comfort without initiating full resuscitation efforts, respecting the client's decision. Choice B is incorrect as it goes against the client's expressed wish to decline resuscitation in her living will. Choice C is not the most appropriate response as it does not directly address the client's immediate concern of difficulty breathing and lacks specificity. Choice D, although focusing on comfort measures, is less specific than the correct choice A in addressing the client's immediate need for assistance with breathing.

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