Nursing Elites

1. The nurse observes a UAP performing oral hygiene on an unconscious client who is lying in a flat side-lying position with an emesis basin on a towel under the chin. Which action should the nurse take?

• A. Stop the procedure and tell the UAP to place the client in a Fowler's position
• B. Praise the UAP for doing the oral hygiene but encourage family participation
• C. Tell the UAP to continue because the unconscious client is positioned safely
• D. Enroll the UAP in a hospital education class on conducting safe client care

Correct answer: C

Rationale: The correct answer is to tell the UAP to continue because the unconscious client is positioned safely for oral care. Placing an unconscious client in a side-lying position helps prevent aspiration, and having an emesis basin under the chin is appropriate to catch any fluids. Therefore, the nurse should acknowledge that the UAP is performing the procedure correctly. Choices A, B, and D are incorrect. Placing the client in a Fowler's position is not necessary for this procedure as the client is already positioned safely. Praise and encouragement for family participation are important aspects but not the immediate action needed in this scenario. Enrolling the UAP in a hospital education class is not warranted as the current procedure is being performed correctly.

2. When reinforcing diet teaching for a client diagnosed with hypokalemia, which foods should the PN encourage the client to eat? Select All That Apply

• A. Orange juice, oranges, bananas
• B. All are applicable
• C. Collard greens, kale, turnips
• D. Soybeans, lima beans, spinach

Correct answer: B

Rationale: The correct answer is B: All are applicable. Foods rich in potassium, such as orange juice, oranges, bananas, collard greens, kale, soybeans, lima beans, and spinach, are essential for managing hypokalemia. These options provide a significant source of potassium, which helps in maintaining normal heart and muscle function. Choice A is incorrect because it does not include all the appropriate potassium-rich foods. Choice C is incorrect as it only mentions vegetables rich in potassium, missing out on other essential sources like fruits and beans. Choice D is incorrect as it lacks key potassium-rich foods like oranges and bananas.

3. Based on the computer documentation in the EMR, which action should the PN implement?

• A. Give the rubella vaccine subcutaneously
• B. Observe the mother breastfeeding her infant
• C. Call the nursery for the infant's blood type results
• D. Administer hydrocodone/acetaminophen one tablet for pain

Correct answer: A

Rationale: The rubella vaccine is crucial for preventing rubella infection, which can cause severe congenital disabilities if contracted during pregnancy. Administering the vaccine subcutaneously is the correct action based on EMR documentation. Observing breastfeeding, calling the nursery for blood type results, and administering pain medication are not indicated by the EMR documentation and are not relevant to the situation described in the question.

4. Before administering an antibiotic that can cause nephrotoxicity, which lab value is most important for the nurse to review?

• A. Hemoglobin and Hematocrit
• B. Serum Calcium
• C. Serum Creatinine
• D. WBC

Correct answer: C

Rationale: The correct answer is C: Serum Creatinine. Serum creatinine is a key indicator of kidney function. Reviewing this value is crucial as it helps assess the client's risk for nephrotoxicity before administering the antibiotic. Elevated serum creatinine levels can indicate impaired kidney function, which would increase the risk of nephrotoxicity. Choices A, B, and D are not as directly related to kidney function and nephrotoxicity. Hemoglobin and hematocrit levels assess for anemia, serum calcium levels monitor calcium balance, and WBC count evaluates for infections. While these values are important for overall patient assessment, they are not as specific to assessing nephrotoxicity risk as serum creatinine.

5. A client confides to the nurse that the client has been substituting herbal supplements for high blood pressure instead of the prescribed medication. How should the nurse respond first?

• A. Ask the client's reason for choosing to take herbs instead of prescribed medication
• B. Reinforce that the healthcare provider prescribed the medication for a reason
• C. Have the client use their own words to describe complications of high blood pressure
• D. Point out the risks of not taking the prescribed medication rather than herbal supplements

Correct answer: A

Rationale: The correct answer is to ask the client's reason for choosing to take herbs instead of prescribed medication. Understanding the client's rationale for using herbal supplements allows the nurse to explore any misconceptions and provide education on the importance of the prescribed medication. Choice B is incorrect because simply reinforcing the prescription does not address the client's concerns or reasons for using herbal supplements. Choice C does not directly address the immediate concern of the client substituting medication with herbal supplements. Choice D focuses on the risks of not taking the prescribed medication rather than herbal supplements, which is not the most appropriate initial response.

Similar Questions