Nursing Elites

1. The UAP reports to the nurse that a client refused to bathe for the third consecutive day. Which action is best for the nurse to take?

• A. Explain the importance of good hygiene to the client
• B. Ask family members to encourage the client to bathe
• C. Reschedule the bath for the following day
• D. Ask the client why the bath was refused

Correct answer: D

Rationale: The correct action for the nurse to take is to ask the client why the bath was refused. Understanding the client's reason for refusal is crucial in identifying and addressing any underlying concerns or issues that may be contributing to the refusal. This approach promotes open communication, client-centered care, and helps in developing a plan of care that is tailored to the client's needs and preferences. Choices A, B, and C do not directly address the root cause of the refusal and may not effectively resolve the situation.

2. A client post-thyroidectomy is being monitored for signs of hypocalcemia. Which of the following symptoms should the nurse be most concerned about?

• A. Tingling in the hands and around the mouth.
• B. Nausea and vomiting.
• C. Constipation.
• D. Bradycardia.

Correct answer: A

Rationale: The correct answer is A: Tingling in the hands and around the mouth. This symptom is a classic sign of hypocalcemia, which can occur after thyroidectomy if the parathyroid glands were inadvertently damaged during surgery. Nausea and vomiting (Choice B) are not specific to hypocalcemia. Constipation (Choice C) is not a typical symptom of hypocalcemia. Bradycardia (Choice D) is more commonly associated with hypothyroidism rather than hypocalcemia.

3. Which assessment finding would most likely indicate a complication of enteral tube feeding?

• A. Abdominal distension
• B. Weight gain
• C. Decreased bowel sounds
• D. Diarrhea

Correct answer: A

Rationale: Abdominal distension in a patient receiving enteral tube feeding may indicate a complication such as intolerance to feeding, delayed gastric emptying, or obstruction. Abdominal distension is a common sign of gastrointestinal issues related to enteral tube feeding. Weight gain is typically an expected outcome if the patient is receiving adequate nutrition. Decreased bowel sounds may indicate decreased motility but are not specific to enteral tube feeding complications. Diarrhea can occur due to various reasons, including infections, medications, or dietary changes, but it is not the most likely indication of a complication in enteral tube feeding.

4. When a small fire breaks out in the kitchen of a long-term care facility, which task is most important for the nurse to perform instead of assigning to a UAP?

• A. Close the doors to all residents' rooms
• B. Offer comfort and reassurance to each resident
• C. Identify the method for transporting and evacuating each resident
• D. Provide blankets to each resident for use during evacuation

Correct answer: C

Rationale: During a fire emergency in a long-term care facility, the most critical task for the nurse is to identify the method for transporting and evacuating each resident. This task requires quick decision-making and critical thinking, which are essential in ensuring the safety and well-being of the residents. Closing the doors to residents' rooms (Choice A) can help contain the fire but should not be the nurse's top priority. While offering comfort and reassurance (Choice B) is important, the immediate focus should be on ensuring safe evacuation. Providing blankets (Choice D) is also important but comes after ensuring safe transportation and evacuation plans are in place.

5. Which laboratory value is most important to monitor for a patient receiving heparin therapy?

• A. Platelet count
• B. Prothrombin time (PT)
• C. Partial thromboplastin time (PTT)
• D. International normalized ratio (INR)

Correct answer: C

Rationale: The correct answer is C, Partial thromboplastin time (PTT). PTT is monitored to assess the therapeutic effect of heparin therapy. It helps ensure that the heparin levels are within the desired range to prevent either clotting or excessive bleeding. Platelet count (A) is important but does not directly assess heparin's therapeutic effect. Prothrombin time (PT) (B) and International normalized ratio (INR) (D) are used to monitor patients on warfarin, not heparin therapy.

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