Nursing Elites

1. The nurse is preparing task assignments for the day. Which task should the nurse assign to a nursing assistant?

• A. Monitoring for bleeding for a client who has just undergone cardiac catheterization
• B. Assisting a client who is getting up to ambulate for the first time after surgery
• C. Providing oral care to an unconscious client who requires oral care
• D. Completing the preoperative checklist for a client scheduled for a liver biopsy

Correct answer: C

Rationale: When delegating tasks, the nurse must consider the state nursing practice act guidelines and job descriptions. Providing oral care to an unconscious client is a task suitable for delegation to a nursing assistant. The nurse should give clear instructions on adapting the procedure for the client's needs and the signs of complications to watch for. Monitoring for bleeding after cardiac catheterization necessitates immediate nursing assessment, which requires critical thinking and intervention that exceeds a nursing assistant's scope of practice. Assisting a client with ambulation post-surgery carries the risk of orthostatic hypotension and should be performed by a licensed nurse. Completing a preoperative checklist for a client scheduled for a liver biopsy involves critical assessment and preparation that are within the nurse's scope of practice.

2. A nurse in charge of a long-term care facility who is working with a nursing assistant on the night shift prepares to take a break. To ensure client safety during the break, which actions should the nurse take? Select all that apply.

• A. Asking the nursing assistant to contact the health care provider during the nurse’s break if a client’s pain medication is not effective
• B. Informing the nursing assistant that she is leaving the nursing unit to get a cup of coffee from a vending machine in the lobby
• C. Asking the nursing assistant to administer a medication placed at the client's bedside if the client awakens
• D. Conducting client rounds before taking the break

Correct answer: D

Rationale: The nurse is responsible for ensuring client safety at all times and must not leave the nursing unit for any reason during the shift. The nurse’s break should be taken in a designated area located on the nursing unit. Before taking the break, the nurse should check all clients to ensure that they are safe and comfortable and that their needs have been met. Conducting client rounds before taking the break is crucial to assess the clients' conditions and address any immediate needs, ensuring their safety. Asking the nursing assistant to contact the health care provider during the nurse’s break is not appropriate as the nurse should handle this responsibility. Leaving the nursing unit to get coffee is not recommended as the nurse should stay within the unit to respond promptly to any client needs. Asking the nursing assistant to administer medication or make clinical decisions is outside the scope of their practice and should not be delegated.

3. What should be the primary action for a client who has just vomited 300 cc of bright red blood?

• A. Document the vomiting.
• B. Increase IV fluids.
• C. Get a complete blood count.
• D. Check the blood pressure.

Correct answer: D

Rationale: The correct first action for a client who has just vomited 300 cc of bright red blood is to check the blood pressure. This assessment is crucial to evaluate for hypotension, which could indicate significant blood loss and the need for immediate intervention. Documenting the vomiting is important for the client's medical record but not the initial priority. Increasing IV fluids and getting a complete blood count are necessary steps but should follow the assessment of the client's hemodynamic status.

4. Priorities designated as intermediate by the nurse are:

• A. the nonemergency, non-life-threatening needs of the client.
• B. those tasks that can be delegated to assistive personnel.
• C. those tasks that can be performed at the end of the shift.
• D. those tasks that can be performed at any time

Correct answer: A

Rationale: Priorities designated as intermediate by the nurse are those that are not urgent but still important, such as the nonemergency, non-life-threatening needs of the client. They do not impact the client's immediate physiological status but require attention. Intermediate priorities may need the skill level of an RN for completion and may have specific time requirements. Choices B, C, and D are incorrect because the priority being intermediate doesn't mean it can be delegated, done at a specific time, or done at any time; it simply indicates a non-urgent but necessary task for the client's well-being.

5. All of the following are causes of vaginal bleeding in late pregnancy except:

• A. Placenta previa.
• B. Eclampsia.
• C. Abruptio placentae.
• D. Uterine rupture.

Correct answer: B

Rationale: The correct answer is B: Eclampsia. Eclampsia is a disorder of pregnancy characterized by hypertension, proteinuria, and edema. This condition can cause seizures and/or coma but does not typically present with vaginal bleeding. Choices A, C, and D are abnormal conditions that can cause bleeding, particularly in the third trimester. Placenta previa (choice A) is a condition where the placenta partially or completely covers the cervix, leading to vaginal bleeding. Abruptio placentae (choice C) is the premature separation of the placenta from the uterine wall, causing vaginal bleeding. Uterine rupture (choice D) is a serious obstetrical emergency where the uterus tears during pregnancy or childbirth, resulting in severe bleeding.

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