Nursing Elites

1. Which direction given to the nursing assistant is most likely to accomplish the task of getting a urine specimen delivered to the lab immediately after collection?

• A. "Make it a stat delivery."?
• B. "Please do it as soon as you can after break."?
• C. "This client is delirious, and we're worried about urinary sepsis."?
• D. "Take this client to the bathroom now and collect a urine specimen from this voiding. Take the specimen to the lab immediately."?

Correct answer: D

Rationale: Effective delegation depends on clear, concise direction that leaves no room for question or interpretation on the part of the one being delegated to. In this scenario, the most appropriate direction is to ensure the urine specimen is collected promptly and delivered to the lab immediately. Choice A is too vague and does not specify the urgency required. Choice B does not emphasize the immediate need for the specimen to be delivered. Choice C introduces unnecessary medical information that is beyond the scope of a nursing assistant and may cause confusion. Therefore, choice D is the correct answer as it provides clear instructions for immediate action without room for misunderstanding.

2. In an emergency situation, the nurse determines whether a client has an airway obstruction. Which of the following does the nurse assess?

• A. ability to speak
• B. ability to hear
• C. oxygen saturation
• D. adventitious breath sounds

Correct answer: A

Rationale: In an emergency situation, assessing the client's ability to speak is crucial in determining airway obstruction. If a client can speak, it indicates that the airway is patent and not completely obstructed. Choices B and C, assessing the ability to hear and oxygen saturation, are not directly indicative of an airway obstruction. Choice D, adventitious breath sounds, may be present in conditions like asthma or pneumonia but are not specific to determining an airway obstruction.

3. Which of the following microorganisms are considered normal body flora?

• A. staphylococcus on the skin
• B. streptococcus in the nares
• C. candida albicans in the vagina
• D. pseudomonas in the blood

Correct answer: A

Rationale: Staphylococcus is considered normal body flora as it is commonly found on the skin, being a part of the normal microbiota. While streptococcus in the nares can be part of the normal flora of the upper respiratory tract, it is not as common or as widespread as staphylococcus on the skin. Candida albicans in the vagina is not considered normal flora; it is a common opportunistic pathogen in the vagina. Pseudomonas in the blood is also not considered normal body flora; pseudomonas is not typically found in the blood as part of the normal microbiota.

4. Which of the following adverse effects should the client on Floxin be alerted to?

• A. stunting of height in teens and young adults
• B. propensity for anovulatory uterine bleeding
• C. intractable diarrhea
• D. tendon rupture

Correct answer: D

Rationale: The correct answer is tendon rupture. Floxin is a quinolone antibiotic commonly used in respiratory infections and pelvic/reproductive infections. One of the rare adverse effects associated with quinolones is tendon sheath rupture, often affecting the Achilles tendon. Therefore, patients taking Floxin should be alerted to the possibility of tendon rupture. Choices A, B, and C are incorrect as they are not typically associated with Floxin use and are not common adverse effects of quinolone antibiotics. Stunting of height is not a recognized adverse effect of Floxin. Anovulatory uterine bleeding is not a known side effect of quinolones. Intractable diarrhea is not a common adverse effect of Floxin.

5. When assessing a client's risk for elimination impairment, which of the following factors is least relevant?

• A. current medications
• B. ambulation abilities
• C. family history
• D. hydration status

Correct answer: C

Rationale: When assessing a client's risk for elimination impairment, family history is the least relevant factor to consider. Current medications can affect elimination functions through side effects, ambulation abilities can impact mobility to access toileting facilities, and hydration status directly influences urinary output and bowel function. Family history, although providing some context, does not have a direct impact on the client's current risk of elimination impairment.

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