Nursing Elites

1. What are the priority nursing assessments for a patient who has just undergone major surgery?

• A. Providing analgesia as prescribed
• B. Monitoring for signs of infection
• C. Assessing the surgical site for bleeding
• D. Monitoring the patient's vital signs

Correct answer: B

Rationale: The correct answer is to monitor for signs of infection. After major surgery, one of the priority nursing assessments is to watch for signs of infection, such as increased temperature, redness, swelling, or drainage at the surgical site. While providing analgesia is important for pain management, monitoring for infection takes precedence as it can lead to severe complications if not detected early. Assessing the surgical site for bleeding is crucial but is usually more relevant immediately after surgery. Monitoring the patient's vital signs is essential, but the specific focus on infection assessment is crucial in the immediate postoperative period.

2. A healthcare provider is assessing a patient with dehydration. Which finding indicates the patient's condition is worsening?

• A. Dry mucous membranes.
• B. Tachycardia and low blood pressure.
• C. Bradycardia and shallow respirations.
• D. Clear lung sounds.

Correct answer: B

Rationale: Tachycardia and low blood pressure are indicative of worsening dehydration in a patient. Tachycardia is the body's compensatory mechanism to maintain cardiac output in response to decreased intravascular volume, while low blood pressure reflects inadequate perfusion due to decreased fluid levels. Bradycardia and shallow respirations are not typical findings in worsening dehydration, and clear lung sounds do not directly correlate with the severity of dehydration.

3. What are the key considerations when administering opioid analgesics to a patient in pain?

• A. Monitoring for respiratory depression
• B. Administering opioid antagonist if needed
• C. Assessing respiratory rate and pain level before administration
• D. Monitoring the patient's level of consciousness

Correct answer: A

Rationale: The correct key consideration when administering opioid analgesics to a patient in pain is monitoring for respiratory depression. Opioids can lead to respiratory depression, making it crucial to carefully monitor the patient's breathing. Administering an opioid antagonist is not a key consideration during the administration of opioids; it is used to reverse opioid effects in cases of overdose, not as a routine practice. Assessing respiratory rate and pain level before administration is important but not the key consideration compared to monitoring for respiratory depression. Monitoring the patient's level of consciousness is also essential but not as critical as monitoring for respiratory depression when administering opioids.

4. A nurse is preparing to perform a 12-lead electrocardiogram (ECG). Which of the following instructions should the nurse provide to the client?

• A. Remain still once the gel pads are attached
• B. I will be placing electrodes on your chest
• C. I will lower the head of your bed so you can sit up
• D. Breathe normally throughout the procedure

Correct answer: A

Rationale: The correct answer is A. Instructing the client to remain still once the gel pads are attached is crucial to obtaining accurate ECG readings. Choice B is incorrect as electrodes are typically placed on the chest, not the breast. Choice C is incorrect because the client should lie flat during an ECG, not sit up. Choice D is incorrect because the client should breathe normally, rather than holding their breath, throughout the procedure.

5. A charge nurse is planning care for a group of clients on a medical-surgical unit. Which of the following tasks should the nurse delegate to an assistive personnel (AP)?

• A. Giving a glycerin suppository to a client for constipation
• B. Evaluating the effectiveness of ibuprofen administered to a client who reported a headache
• C. Discussing dietary changes with a client who has a prescription for a gluten-free diet
• D. Measuring hourly urinary output for a client who is postoperative

Correct answer: D

Rationale: The correct answer is D because measuring hourly urinary output is a task that falls within the scope of practice for assistive personnel. This task involves a technical skill that can be delegated by the charge nurse. Choices A, B, and C require higher-level nursing assessments and interventions that should be performed by licensed nursing staff. Giving a glycerin suppository involves medication administration, evaluating the effectiveness of ibuprofen requires assessment and critical thinking, and discussing dietary changes involves education and assessment of the client's understanding and compliance, all of which are beyond the scope of practice for assistive personnel.

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