Nursing Elites

1. Which task could the nurse safely delegate to the UAP?

• A. Oral feeding of a two-year-old child after application of a hip spica cast
• B. Assessment of the placement and patency of an NG tube
• C. Participation in staff rounds to record notes regarding client goals
• D. Evaluation of a client's incisional pain following narcotic administration

Correct answer: A

Rationale: The correct answer is A because oral feeding of a stable child is a task that can be safely delegated to a UAP. This task does not require nursing assessment or clinical judgment. Choice B involves assessment, which requires the nurse's clinical judgment. Choice C involves recording client goals during staff rounds, which may require interpretation and understanding of the goals set. Choice D involves evaluating a client's pain following medication administration, which requires assessment and clinical judgment by a nurse.

2. Which of the following is NOT a second-line agent used for the treatment of Tuberculosis?

• A. Amikacin
• B. Moxifloxacin
• C. Rifabutin
• D. Cycloserine

Correct answer: C

Rationale: The correct answer is C, Rifabutin. Rifabutin is actually a first-line drug used in the treatment of tuberculosis. Choices A, B, and D (Amikacin, Moxifloxacin, and Cycloserine) are considered second-line agents for tuberculosis treatment. These drugs are used when the first-line medications are either ineffective or cannot be tolerated by the patient.

3. The PN is reviewing instructions for the use of pilocarpine eye drops with a client who has glaucoma. The client replies that the drops are used to anesthetize the eye if eye pain is experienced. What action should the PN implement?

• A. Document in the chart that the client understands the correct action and use of eye drops
• B. Reassure the client that the drops will not be needed often since eye pain in glaucoma is not common
• C. Reteach the client about the action of the eye drops to decrease pressure in the eyes
• D. Explain to the client that the eye drops do not anesthetize the eyes but reduce pressure

Correct answer: C

Rationale: Pilocarpine eye drops are used to reduce intraocular pressure in glaucoma, not to anesthetize the eye. The PN should reteach the client about the purpose of the medication to ensure proper use and understanding, which is crucial for effective treatment. Choice A is incorrect because just documenting understanding without addressing the client's misconception is not enough. Choice B is incorrect as it provides incorrect information about the purpose of the eye drops and may lead to further misunderstanding. Choice D is incorrect as it provides inaccurate information stating that the drops provide pain relief, which is not their primary purpose.

4. During an inspection of a client's fingernails, the nurse notices a suspected abnormality in the shape and character of the nails. Which finding should the nurse document?

• A. Clubbed nails
• B. Splinter hemorrhages
• C. Longitudinal ridges
• D. Koilonychia or spoon nails

Correct answer: A

Rationale: Clubbed nails are a significant finding in clients with chronic hypoxia or lung disease. This abnormality is characterized by an increased curvature of the nails and softening of the nail bed. It can indicate underlying health conditions such as respiratory or cardiovascular issues. Splinter hemorrhages (B) are small areas of bleeding under the nails, typically associated with infective endocarditis. Longitudinal ridges (C) are often a normal age-related change in the nails. Koilonychia or spoon nails (D) present as a concave shape of the nails and are commonly seen in clients with iron deficiency anemia or hemochromatosis. Therefore, documenting clubbed nails is the most relevant abnormality to report and investigate further.

5. When assisting an older male client recovering from a stroke to ambulate with a cane, where should the nurse place the cane in relation to the client's body?

• A. In front of the body to lean on while stepping forward
• B. On the opposite side of the affected extremity
• C. Approximately one foot away from the body to stabilize balance
• D. On the same side as the affected extremity

Correct answer: B

Rationale: The correct answer is B: 'On the opposite side of the affected extremity.' Placing the cane on the opposite side of the affected extremity provides maximum support and stability during ambulation for a client recovering from a stroke. This positioning helps to offload weight from the affected side and improves balance. Choice A is incorrect because placing the cane in front of the body can lead to incorrect weight distribution and instability. Choice C is incorrect as placing the cane one foot away from the body may not provide adequate support and can compromise balance. Choice D is incorrect as placing the cane on the same side as the affected extremity does not offer the necessary balance and support needed for safe ambulation.

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