Nursing Elites

1. Which task could be safely delegated by the nurse to an unlicensed assistive personnel (UAP)?

• A. Accompanying a client who self-administers insulin
• B. Cleansing and dressing a small decubitus ulcer
• C. Monitoring a client's response to passive range of motion exercises
• D. Applying and caring for a client's rectal pouch

Correct answer: D

Rationale: The correct answer is D because tasks like applying and caring for a client's rectal pouch are within the UAP's scope of practice, as they do not require clinical judgment. Choices A, B, and C involve more complex assessments or interventions that require clinical judgment and should be performed by licensed nursing staff.

2. The healthcare provider is caring for a client with severe anemia. Which assessment finding requires immediate intervention?

• A. Pale skin
• B. Increased heart rate
• C. Shortness of breath
• D. Fatigue

Correct answer: C

Rationale: Shortness of breath is a critical sign in severe anemia as it indicates inadequate oxygenation, which can be life-threatening. Immediate intervention is necessary to address this condition. Pale skin (choice A) is a common finding in anemia but not as urgent as shortness of breath. Increased heart rate (choice B) is a compensatory mechanism in anemia to maintain oxygen delivery and is important but not as urgent as addressing inadequate oxygenation. Fatigue (choice D) is a common symptom in anemia but does not indicate an immediate life-threatening situation like shortness of breath does.

3. When conducting diet teaching for a client on a postoperative full liquid diet, which foods should the nurse encourage the client to eat?

• A. Yogurt, milk, and pudding
• B. Tea, lentils, and potato soup
• C. Ice cream, broth, and fruit smoothies
• D. Orange juice, mashed potatoes, and soft cheese

Correct answer: A

Rationale: A full liquid diet includes foods that are liquid or will turn liquid at room temperature. Yogurt, milk, and pudding are appropriate choices as they align with the consistency requirements of a full liquid diet. Choices B, C, and D are incorrect. Tea, lentils, potato soup, ice cream, fruit smoothies, orange juice, mashed potatoes, and soft cheese are not typically part of a full liquid diet. These options either contain solid elements or are not in liquid form, which makes them unsuitable for a postoperative full liquid diet.

4. When assessing a client with a diagnosis of bipolar disorder who reports taking a handful of medications, what information is most important to obtain?

• A. What drugs the client used in the suicide attempt.
• B. When the client last took medications for bipolar disorder.
• C. Whether the client has attempted suicide before.
• D. Which family member has the suicide note.

Correct answer: A

Rationale: The correct answer is to obtain information on what drugs the client used in the suicide attempt. This information is crucial for assessing the severity of the overdose, potential drug interactions, and determining the appropriate treatment plan. Choice B is not as urgent as identifying the drugs taken during the suicide attempt. Choice C, while important, is not as immediately critical as knowing the specific medications involved. Choice D is unrelated to the immediate medical needs of the client.

5. A client tells the nurse, 'I have something very important to tell you if you promise not to tell.' The best response by the nurse is

• A. I must document and report any information.
• B. I can't make such a promise.
• C. That depends on what you tell me.
• D. I must report everything to the treatment team.

Correct answer: B

Rationale: The correct answer is B because the nurse cannot promise confidentiality in this context. It is essential to prioritize the safety and well-being of the client and others. Certain information, such as harm to oneself or others, must be reported to ensure appropriate interventions are taken. Choice A is incorrect because while documentation is important, confidentiality cannot be guaranteed in this situation. Choice C is incorrect as the nurse should not make promises that may conflict with their professional responsibilities. Choice D is incorrect as reporting everything to the treatment team without discretion may breach client confidentiality.

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