Nursing Elites

1. Which task can the RN delegate to an unlicensed assistive personnel (UAP)?

• A. Take a history on a newly admitted client
• B. Adjust the rate of a gastric tube feeding
• C. Check the blood pressure of a 2-hour postoperative client
• D. Check on a client receiving chemotherapy

Correct answer: C

Rationale: The correct answer is C. Checking the blood pressure of a 2-hour postoperative client is a task that can be safely delegated to an unlicensed assistive personnel (UAP) as it falls within their scope of practice. This task is routine and does not require specialized nursing knowledge or critical decision-making. Options A, B, and D involve tasks that require a higher level of training and critical thinking beyond the scope of a UAP. Taking a history, adjusting tube feeding rates, and monitoring a client receiving chemotherapy are responsibilities that should be performed by licensed healthcare providers who have the necessary skills and training.

2. A healthcare professional is screening several clients at a neighborhood health fair. Which of the following assessment findings is the priority for referral for further care?

• A. HR 105/min
• B. BMI 25 kg/m²
• C. BP 148/92
• D. Glucose 45 mg/dL

Correct answer: D

Rationale: The correct answer is D, 'Glucose 45 mg/dL.' Glucose level of 45 mg/dL indicates hypoglycemia, which is a critical condition requiring immediate attention to prevent complications like seizures, loss of consciousness, and even coma. Hypoglycemia can lead to serious adverse outcomes if not promptly addressed. Choices A, B, and C do not represent immediate life-threatening conditions and can be managed as part of routine care, unlike hypoglycemia which demands urgent intervention.

3. A healthcare professional is caring for a client who has a prescription for a stool specimen to be sent to the laboratory to be tested for ova and parasites. Which of the following instructions regarding specimen collection should the healthcare professional provide to the assistive personnel?

• A. Collect at least 2 inches of formed stool.
• B. Wear sterile gloves while obtaining the specimen.
• C. Use a culturette for specimen collection.
• D. Record the date and time the stool was collected.

Correct answer: A

Rationale: To ensure accurate testing, a minimum amount of stool is required for specimen collection, typically at least 2 inches of formed stool. This amount provides an adequate sample for testing. Wearing sterile gloves is important for infection control but is not specifically required for stool specimen collection. Using a culturette is not typically necessary for collecting stool specimens. Recording the date and time the stool was collected is essential to ensure timely processing but does not directly impact the collection of the specimen itself.

4. When assessing the skin of an immobilized patient, what should the nurse do?

• A. Assess the skin every 4 hours.
• B. Limit the amount of fluid intake.
• C. Use a standardized tool such as the Braden Scale.
• D. Have special times for inspection to not interrupt routine care.

Correct answer: C

Rationale: When assessing the skin of an immobilized patient, it is essential to use a standardized tool like the Braden Scale. This tool helps in systematically evaluating the patient's risk of developing pressure ulcers. Assessing the skin every 4 hours (Choice A) may be too frequent or unnecessary unless there are specific concerns or orders. Limiting fluid intake (Choice B) is not directly related to skin assessment in an immobilized patient. Having special times for inspection to avoid interrupting routine care (Choice D) is not as crucial as using a standardized tool for consistent and comprehensive skin assessment.

5. A nurse is caring for a client who has terminal lung cancer. The nurse observes the client’s family assisting with all ADLs. Which of the following rationales for self-care should the nurse communicate to the family?

• A. Allowing the client to function independently will strengthen muscles and promote healing.
• B. The client needs privacy at times for self-reflection and organizing life.
• C. The client’s sense of loss can be lessened through retaining control of some areas of life.
• D. Performing ADLs is a requirement prior to discharge from an acute care facility.

Correct answer: C

Rationale: The correct answer is C. In situations like terminal illness, allowing clients to perform activities of daily living (ADLs) can help maintain their sense of control and dignity, providing comfort and a sense of normalcy amidst their health challenges. Choice A is incorrect because in a terminal stage, the focus is not on muscle strength or promoting physical healing but rather on enhancing the client's emotional well-being. Choice B, while highlighting the importance of privacy, is not directly addressing the client's need for control and autonomy. Choice D is incorrect as the priority in this scenario is not related to discharge requirements but rather the client's emotional and psychological needs during their terminal illness.

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