Nursing Elites

1. The nurse is providing care for a client with severe peripheral arterial disease (PAD). The client reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?

• A. Elevate the legs on pillows
• B. Encourage ambulation and leg exercises
• C. Provide a heating pad for warmth
• D. Offer cold packs when the pain occurs

Correct answer: C

Rationale: Providing warmth can help dilate peripheral vessels and increase blood flow, relieving ischemic pain. In PAD, where there is already compromised blood flow, elevating the legs or applying cold therapy could worsen ischemic pain by further reducing blood flow to the extremities. Encouraging ambulation and leg exercises may be beneficial in other conditions but not suitable for clients with severe PAD experiencing rest ischemia.

2. A 48-year-old client with chronic alcoholism is admitted to the hospital. The nurse would anticipate that the client may be deficient in which vitamins?

• A. Vitamin B and vitamin C
• B. Vitamin D and vitamin E
• C. Vitamin K and vitamin A
• D. Vitamin A and vitamin E

Correct answer: A

Rationale: The correct answer is A. Chronic alcoholism commonly leads to deficiencies in B vitamins, particularly thiamine, and vitamin C. Thiamine deficiency can result in serious neurological issues like Wernicke-Korsakoff syndrome, while vitamin C deficiency can lead to scurvy. Choices B, C, and D are incorrect because vitamin D and E deficiencies are not typically associated with chronic alcoholism.

3. A nurse is working with a new graduate nurse on the delegation of tasks to the unlicensed assistive personnel (UAP). Which task would the new nurse need more teaching about delegating?

• A. Taking a client's blood pressure
• B. Providing oral hygiene for a client
• C. Assessing a client's pain level
• D. Assisting a client with ambulation

Correct answer: C

Rationale: The correct answer is C: Assessing a client's pain level. This task involves clinical judgment and interpretation, which are within the scope of a licensed nurse's practice. Delegating pain assessment to unlicensed personnel could lead to errors in pain management and inappropriate interventions. Choices A, B, and D involve tasks that can be safely delegated to unlicensed assistive personnel as they do not involve interpretation or nursing judgment. Taking a client's blood pressure, providing oral hygiene, and assisting with ambulation are all routine tasks that can be appropriately assigned to UAP under the supervision of a licensed nurse.

4. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?

• A. Apply suction for no more than 10 seconds
• B. Maintain sterile technique
• C. Lubricate 3 to 4 inches of the catheter tip
• D. Withdraw catheter in a circular motion

Correct answer: A

Rationale: The correct answer is to apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia, so it is essential to limit the suctioning time. Maintaining sterile technique (choice B) is important to prevent infections but is not directly related to preventing hypoxia during suctioning. Lubricating the catheter tip (choice C) helps with insertion but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not help prevent hypoxia.

5. An unresponsive male victim of a diving accident is brought to the emergency department where immediate surgery is required to save his life. No family members are available. What action should the nurse take first?

• A. Ask the friend to sign an informed consent.
• B. Notify the unit manager that a court order is needed.
• C. Continue providing life support until a guardian is found.
• D. Proceed with surgery preparation without consent.

Correct answer: D

Rationale: In emergency situations where immediate surgery is required to save a patient's life and no family members are available, consent can be waived to proceed with necessary interventions. The priority in this scenario is to proceed with surgery preparation without waiting for consent, as any delay could jeopardize the patient's life. Asking the friend to sign informed consent or notifying the unit manager for a court order would cause unnecessary delays, which are not advisable in this critical situation. Continuing life support until a guardian is found is not the most appropriate action when immediate surgical intervention is necessary.

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