Nursing Elites

1. What happens when Mrs. Guevarra, a nurse, delegates aspects of the client's care to the nurse-aide, an unlicensed staff member?

• A. Mrs. Guevarra makes the assignment to instruct the staff member
• B. Mrs. Guevarra is assigning the responsibility to the aide but not the accountability for those tasks
• C. Mrs. Guevarra does not need to directly supervise or evaluate the aide
• D. Mrs. Guevarra must know how to perform the task being delegated

Correct answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

2. In some hip surgeries, an epidural catheter for Fentanyl epidural analgesia is given. What is your nursing priority care in such a case?

• A. Instruct the client to observe strict bed rest
• B. Check for epidural catheter drainage
• C. Administer analgesia through the epidural catheter as prescribed
• D. Assess respiratory rate carefully

Correct answer: D

Rationale: The nursing priority care in a case where an epidural catheter for Fentanyl epidural analgesia is given during hip surgeries is to assess the respiratory rate carefully. Respiratory depression is a potential side effect of Fentanyl, especially when administered epidurally. Monitoring the respiratory rate is crucial to detect any signs of respiratory distress promptly. Instructing the client to observe strict bed rest (Choice A) may be necessary but is not the priority over ensuring respiratory function. Checking for epidural catheter drainage (Choice B) and administering analgesia through the epidural catheter as prescribed (Choice C) are important aspects of care, but ensuring adequate ventilation takes precedence to prevent complications.

3. A nurse is teaching a client about strategies to prevent constipation. Which of the following statements by the client indicates an understanding of the teaching?

• A. Drinking four to five glasses of water per day will prevent constipation.
• B. I should consume mineral oil once per day.
• C. Eating foods high in fiber will make elimination easier.
• D. I can skip a meal if I feel bloated.

Correct answer: C

Rationale: The correct answer is C. Eating foods high in fiber increases stool bulk and promotes easier elimination, thus preventing constipation. Choices A, B, and D are incorrect. Drinking water is important, but the emphasis should be on high-fiber foods. Mineral oil is not a recommended first-line treatment for constipation, and skipping meals can disrupt regular bowel movements, potentially leading to constipation.

4. Each statement is true of rickets, except one. Which is the exception?

• A. Rickets is being diagnosed more frequently in the United States.
• B. Rickets is caused by vitamin C deficiency.
• C. Tachetic deformities such as bow legs or knock-knees develop.
• D. A narrow and distorted chest occurs.

Correct answer: B

Rationale: Rickets is caused by vitamin D deficiency, not vitamin C deficiency. It usually occurs in children who are 1 to 3 years old. The name rickets came from the word 'wrikken,' meaning 'to bend or twist.' Common manifestations of rickets include tachetic deformities like bow legs or knock-knees, a narrow and distorted chest, and failure of the epiphyses of bones to develop normally, resulting in twisted and warped bones. While the diagnosis of rickets may be increasing in the United States, it is not caused by a lack of vitamin C.

5. What outcome has been shown to be a benefit of breastfeeding that directly impacts the mother?

• A. conserving calcium stores
• B. contracting the uterus
• C. protecting against future hypertension
• D. speeding the resumption of ovulation

Correct answer: B

Rationale: The correct answer is B, contracting the uterus. Breastfeeding helps contract the uterus after childbirth, reducing postpartum bleeding and helping the uterus return to its pre-pregnancy size more quickly. Choices A, C, and D are incorrect because conserving calcium stores, protecting against future hypertension, and speeding the resumption of ovulation are not direct benefits of breastfeeding to the mother.

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