Nursing Elites

1. When caring for an immobile client, what nursing diagnosis has the highest priority?

• A. Risk for fluid volume deficit.
• B. Impaired gas exchange.
• C. Risk for impaired skin integrity.
• D. Altered tissue perfusion.

Correct answer: B

Rationale: When caring for an immobile client, the nursing diagnosis with the highest priority is impaired gas exchange. This is because impaired gas exchange implies difficulty with breathing, which is essential for sustaining life. Adequate oxygenation is crucial for all bodily functions, and any impairment in gas exchange can lead to serious complications, making it the priority nursing diagnosis to address in an immobile client. Choices A, C, and D are important considerations as well when caring for an immobile client, but they are secondary to impaired gas exchange. Risk for fluid volume deficit may occur due to immobility, but ensuring proper gas exchange takes precedence as it directly impacts the client's immediate survival. Risk for impaired skin integrity is a concern in immobile clients but does not pose an immediate threat to life like impaired gas exchange. Altered tissue perfusion is also critical but is usually a consequence of impaired gas exchange, reinforcing the priority of addressing gas exchange first.

2. While observing an unlicensed assistive personnel (UAP) providing a total bed bath for a confused and lethargic client, the nurse notes the UAP soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take?

• A. Remove the basin of water from the client’s bed immediately
• B. Remind the UAP to dry between the client’s toes completely
• C. Advise the UAP that this procedure may lead to skin damage
• D. Add skin cream to the basin of water while the foot is soaking

Correct answer: B

Rationale: The correct action for the nurse to take in this situation is to remind the unlicensed assistive personnel (UAP) to dry between the client’s toes completely. Failing to dry between the toes can lead to skin breakdown due to excessive moisture accumulation. Proper drying is essential to maintain skin integrity and prevent complications in the client's care. Removing the basin of water immediately may disrupt the care process and not address the root cause of the issue. Advising about potential skin damage is not as direct and actionable as reminding to dry between the toes. Adding skin cream to the water may not be appropriate without specific orders and can potentially worsen the situation by increasing moisture.

3. The healthcare provider is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?

• A. Low serum albumin level
• B. Low serum transferrin level
• C. High hemoglobin level
• D. High cholesterol level

Correct answer: A

Rationale: A low serum albumin level is the most reliable indicator of chronic protein malnutrition. Serum albumin levels reflect long-term protein status, and a significantly lowered level usually indicates ongoing protein deficiency. Other laboratory values, such as serum transferrin, hemoglobin, or cholesterol levels, may be affected by various factors and conditions, but serum albumin is a more specific marker for chronic protein malnutrition.

4. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

• A. Complete the intermittent suction of the nasopharynx.
• B. Reposition the pulse oximeter clip to obtain a new reading.
• C. Stop suctioning until the pulse oximeter reading is above 95%.
• D. Apply an oxygen mask over the client’s nose and mouth.

Correct answer: A

Rationale: A stable oxygen saturation reading of 94% indicates that the nurse can continue with the suctioning procedure. It is within an acceptable range, and there is no immediate need to interrupt the procedure. Continuing with the suctioning will help maintain airway patency and promote adequate oxygenation. Choice B is incorrect because repositioning the pulse oximeter clip is unnecessary when the reading is stable. Choice C is incorrect as there is no evidence to support stopping the suctioning procedure solely based on the oxygen saturation reading of 94%. Choice D is not the best action at this point, as applying an oxygen mask is not indicated when the oxygen saturation is stable and within an acceptable range.

5. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?

• A. Take measures to promote as much comfort as possible.
• B. Report any signs of drug addiction to the nurse immediately.
• C. Wait until the client's pain is gone before assisting with personal care.
• D. This client's pain will be difficult to manage, as the cause is unknown.

Correct answer: A

Rationale: The correct instruction for the unlicensed assistive personnel (UAP) preparing to assist a client with intractable pain is to take measures to promote as much comfort as possible. Intractable pain is resistant to relief, so ensuring comfort during all activities, including a bed bath, is crucial to enhance the client's well-being and quality of care.

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