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 client with a history of hypertension is prescribed a diuretic. Which of the following laboratory values should the nurse monitor to evaluate the effectiveness of the medication?

• A. Monitor serum calcium levels.
• B. Monitor serum potassium levels.
• C. Monitor serum sodium levels.
• D. Monitor serum magnesium levels.

Correct answer: B

Rationale: The correct answer is to monitor serum potassium levels. When a client is prescribed a diuretic, monitoring serum potassium levels is essential to evaluate the medication's effectiveness and to detect potential electrolyte imbalances. Diuretics can cause potassium loss, leading to hypokalemia, which can have serious consequences such as cardiac arrhythmias. Monitoring serum calcium levels (Choice A) is not typically required when assessing the effectiveness of diuretics. Similarly, monitoring serum sodium levels (Choice C) is important for other conditions but is not the primary concern when evaluating diuretic therapy. Monitoring serum magnesium levels (Choice D) is also important, but potassium levels are more critical in assessing diuretic effectiveness and preventing complications.

3. A charge nurse is discussing the responsibility of nurses caring for clients who have a Clostridium difficile infection. Which of the following information should the nurse include in the teaching?

• A. Assign the client to a room with a negative air-flow system.
• B. Use alcohol-based hand sanitizer when leaving the client's room.
• C. Clean contaminated surfaces in the client's room with a phenol solution.
• D. Have family members wear a gown and gloves when visiting.

Correct answer: D

Rationale: When caring for clients with Clostridium difficile infection, it is important to prevent the transmission of spores. Having family members wear a gown and gloves when visiting helps reduce the spread of the infection. Choices A, B, and C are incorrect because assigning the client to a room with a negative air-flow system, using alcohol-based hand sanitizer, and cleaning surfaces with a phenol solution are not specific measures targeted at preventing the transmission of Clostridium difficile spores.

4. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, 'You are not putting that hose down my throat.' Which of the following statements should the nurse make?

• A. 'I can see that this is upsetting you.'
• B. 'It is necessary for your treatment.'
• C. 'It will be over quickly, and you will feel better.'
• D. 'Let me explain again why this procedure is important.'

Correct answer: A

Rationale: In this situation, the nurse should acknowledge the client's feelings by stating, 'I can see that this is upsetting you.' This response validates the client's emotions and demonstrates empathy, which can help build trust and rapport. Choice B is too direct and might not address the client's emotional state. Choice C focuses on the outcome rather than the client's current distress. Choice D does not directly address the client's feelings of distress and may not effectively alleviate their anxiety.

5. During the initial physical assessment of a newly admitted client with a pressure ulcer, an LPN observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?

• A. The nurse should have also initiated a plan to increase activity.
• B. The nurse provided supportive nursing care for the well-being of the client.
• C. Debridement of the pressure ulcer should have been performed before applying the dressing.
• D. Treatment should not have been initiated until the healthcare provider's prescriptions were received.

Correct answer: B

Rationale: The correct answer is B. Providing supportive nursing care, such as applying emollients and reinforcing the dressing on the pressure ulcer, meets the immediate needs of the client and is in line with legal and professional standards. Option A is incorrect because increasing activity may not be directly related to the immediate skin care needs of the client. Option C is incorrect as debridement might not be immediately necessary based on the initial assessment. Option D is incorrect as nurses are often authorized to initiate treatments within their scope of practice without waiting for healthcare provider prescriptions, especially for routine care like skin moisturization and dressing reinforcement.

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