Nursing Elites

1. The nursing student is discussing with a preceptor the delegation of tasks to an unlicensed assistive personnel (UAP). Which tasks, delegated to a UAP, indicates the student needs further teaching about the delegation process?

• A. Assist a client post cerebral vascular accident to ambulate
• B. Feed a 2-year-old in balanced skeletal traction
• C. Care for a client with discharge orders
• D. Collect a sputum specimen for acid-fast bacillus

Correct answer: C

Rationale: Caring for a client with discharge orders involves tasks that require critical thinking and clinical judgment, which are beyond the scope of a UAP. Delegating this task to a UAP can compromise patient safety and outcomes. The correct answer is C. Choices A, B, and D are appropriate tasks to delegate to a UAP based on their training and scope of practice. Assisting a client to ambulate, feeding a pediatric patient in traction, and collecting a sputum specimen are tasks that can be safely performed by a UAP under appropriate supervision.

2. A client with Cushing's syndrome presents with excessive bruising and elevated blood glucose. What action should the nurse take first?

• A. Check the client's blood glucose level.
• B. Administer insulin per sliding scale protocol.
• C. Administer intravenous fluids.
• D. Check the client's skin for signs of bruising.

Correct answer: A

Rationale: Excessive bruising and elevated blood glucose are common symptoms of Cushing's syndrome. The nurse should first check the client's blood glucose level to assess and address the hyperglycemia promptly. Administering insulin or IV fluids would be premature without knowing the current blood glucose level. Checking the skin for bruising, although important for overall assessment, does not address the immediate concern of elevated blood glucose.

3. A client with chronic obstructive pulmonary disease (COPD) is admitted with increasing shortness of breath. What is the nurse's priority action?

• A. Administer oxygen via nasal cannula.
• B. Reposition the client to improve breathing.
• C. Perform chest physiotherapy.
• D. Encourage the client to cough and deep breathe.

Correct answer: A

Rationale: The correct answer is A: Administer oxygen via nasal cannula. Oxygen therapy is the priority intervention for a client with COPD experiencing increasing shortness of breath. It helps improve oxygenation and relieve respiratory distress. Choice B is not the priority as oxygenation needs to be addressed first. Choice C, chest physiotherapy, may be beneficial but is not the immediate priority in this situation. Choice D, encouraging the client to cough and deep breathe, is not the priority intervention when oxygenation is compromised.

4. A client reports unilateral leg swelling after a long flight. What complication is the nurse most concerned about?

• A. Monitor for signs of a pulmonary embolism.
• B. Assess for signs of dehydration.
• C. Monitor for signs of compartment syndrome.
• D. Check the client’s oxygen saturation levels.

Correct answer: A

Rationale: The correct answer is A. Unilateral leg swelling following a long flight may indicate a pulmonary embolism, which is a life-threatening complication requiring immediate attention. Pulmonary embolism occurs when a blood clot travels to the lungs, potentially blocking blood flow and leading to serious complications. Choices B, C, and D are incorrect because dehydration, compartment syndrome, and oxygen saturation levels are not typically associated with unilateral leg swelling after a long flight. While dehydration can cause leg cramps, compartment syndrome is more commonly associated with trauma or injury, and oxygen saturation levels are not the primary concern in this scenario.

5. The nurse is caring for a client who is post-op after a hip replacement. Which of the following nursing actions is most appropriate to prevent dislocation of the hip?

• A. Place an abduction pillow between the client's legs.
• B. Use an abduction pillow between the client's legs.
• C. Encourage the client to cross their legs while sitting.
• D. Encourage the client to sit upright for long periods.

Correct answer: B

Rationale: Using an abduction pillow between the client's legs is the most appropriate nursing action to prevent dislocation after hip replacement surgery. An abduction pillow helps maintain proper alignment and prevents the hip from dislocating. Placing the client in a high Fowler's position (Choice A) or encouraging them to sit upright for long periods (Choice D) may not provide the necessary support and stability needed to prevent hip dislocation. Encouraging the client to cross their legs while sitting (Choice C) can increase the risk of hip dislocation and should be avoided.

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