Nursing Elites

1. The nurse is responsible for several elderly clients, including a client on bed rest with a skin tear and hematoma from a fall 2 days ago. What is the best care assignment for this client?

• A. Assign an RN to supervise a nursing assistant for skin care
• B. Assign a nursing assistant to help the client with self-care activities
• C. Delegate complete care to an unlicensed assistive personnel
• D. Supervise a nursing assistant for skin care

Correct answer: D

Rationale: In this scenario, the best care assignment for the client with a skin tear and hematoma is to supervise a nursing assistant for skin care. This ensures proper wound care while utilizing the skills of the nursing assistant effectively. Assigning an RN to supervise the nursing assistant is appropriate as it provides the necessary expertise for wound care supervision. Delegating complete care to an unlicensed assistive personnel may not be suitable for a client with specific wound care needs. Helping the client with self-care activities may not directly address the urgent need for proper wound care in this situation.

2. A client with chronic kidney disease is receiving erythropoietin injections. What laboratory value should the nurse monitor to evaluate the effectiveness of the treatment?

• A. Serum potassium
• B. Hemoglobin
• C. White blood cell count
• D. Platelet count

Correct answer: B

Rationale: The correct answer is B: Hemoglobin. Erythropoietin stimulates the production of red blood cells, leading to an increase in hemoglobin levels. Monitoring hemoglobin is crucial to assess the effectiveness of the treatment. Choices A, C, and D are incorrect. Serum potassium levels are often monitored in chronic kidney disease, but it is not the primary parameter to evaluate the effectiveness of erythropoietin therapy. White blood cell count and platelet count are not directly influenced by erythropoietin injections for chronic kidney disease.

3. To auscultate for a carotid bruit, where should the nurse place the stethoscope?

• A. Base of the neck on the right side
• B. Above the clavicle
• C. Over the sternum
• D. Over the trachea

Correct answer: A

Rationale: To auscultate for a carotid bruit, the nurse should place the stethoscope at the base of the neck, near the carotid artery. A carotid bruit is an abnormal sound that indicates turbulent blood flow in the carotid artery, potentially due to arterial narrowing or atherosclerosis. Placing the stethoscope above the clavicle, over the sternum, or over the trachea would not provide the nurse with the optimal location to assess for carotid artery abnormalities.

4. When teaching a group of mothers of young children about emergency care for poisoning, which of the following statements should be included?

• A. Induce vomiting immediately after the poison ingestion
• B. Call the local Poison Control Center after inducing vomiting
• C. Call the Poison Control Center prior to any interventions
• D. Take the child to the emergency department before calling the Poison Control Center

Correct answer: C

Rationale: The correct statement to include when teaching about emergency care for poisoning is to call the Poison Control Center prior to any interventions. This is important because the Poison Control Center can provide guidance on the appropriate steps to take based on the type of poisoning, the amount ingested, and the age of the child. Inducing vomiting without professional advice can sometimes do more harm than good. Choice A is incorrect because inducing vomiting immediately is not recommended without consulting with professionals. Choice B is incorrect as it suggests calling the Poison Control Center after inducing vomiting, which is not the recommended sequence. Choice D is incorrect because it is advisable to contact the Poison Control Center first before taking the child to the emergency department.

5. An older male client, who is a retired chef, is hospitalized with a diabetic ulcer on his foot. His daughter tells the nurse that her father has become increasingly obsessed with the way his food is prepared in the hospital. The nurse's response should be based on what information?

• A. His daughter's observations suggest the client is depressed
• B. His compulsiveness about food may indicate new cognitive decline
• C. Obsessiveness with food is common in diabetic clients
• D. If the client was compulsive about food when he was younger, the aging process can magnify this

Correct answer: D

Rationale: Age can magnify pre-existing compulsive tendencies. If the client was detail-oriented about food earlier in life, this behavior may intensify with aging. It's important to acknowledge and address the client's concerns respectfully. Choices A, B, and C are incorrect because the daughter's observations do not necessarily point to depression, the compulsiveness about food does not indicate new cognitive decline without further assessment, and obsessiveness with food is not specifically common in diabetic clients.

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