Nursing Elites

1. The unlicensed nursing assistant is applying elastic compression stockings to the client. Which action by the assistant warrants immediate intervention by the nurse?

• A. The assistant is putting the stockings on while the client is in the chair.
• B. The assistant inserted two (2) fingers under the proximal end of the stocking.
• C. The assistant elevated the feet while lying down to put on the stockings.
• D. The assistant made sure the toes were warm after putting the stockings on.

Correct answer: A

Rationale: The correct answer is A because compression stockings should be applied while the client is lying down to prevent pooling of blood in the legs, which can occur when the client is sitting or standing. Choice B is not a cause for immediate intervention as inserting two fingers under the proximal end of the stocking helps ensure proper fit. Choice C demonstrates the correct technique of elevating the feet while lying down to put on the stockings. Choice D also shows good care by making sure the toes were warm after putting the stockings on.

2. The client diagnosed with diabetes mellitus type 2 is admitted to the hospital with cellulitis of the right foot secondary to an insect bite. Which intervention should the nurse implement first?

• A. Administer intravenous antibiotics
• B. Apply warm moist packs every two hours
• C. Elevate the right foot on two pillows
• D. Teach the client about skin and foot care

Correct answer: A

Rationale: Administering intravenous antibiotics is the priority intervention in this situation. Cellulitis is a bacterial infection that can spread rapidly, especially in individuals with diabetes. Immediate antibiotic therapy is crucial to prevent the infection from worsening and causing serious complications. Applying warm moist packs, elevating the foot, and teaching the client about skin and foot care are important interventions but should come after initiating antibiotic treatment to address the underlying infection.

3. Which laboratory data indicate the client’s pancreatitis is improving?

• A. The amylase and lipase serum levels are decreased
• B. The white blood cell count (WBC) is decreased
• C. The conjugated and unconjugated bilirubin levels are decreased
• D. The blood urea nitrogen (BUN) serum level is decreased

Correct answer: A

Rationale: The correct answer is A. Amylase and lipase are specific markers for pancreatitis. A decrease in their serum levels indicates improvement in pancreatitis. Choice B, a decreased white blood cell count (WBC), is more indicative of an improvement in infection rather than pancreatitis. Choices C and D, decreased bilirubin levels and blood urea nitrogen (BUN) levels respectively, are not specific markers for pancreatitis improvement.

4. Clinitest is used in testing the urine of a client for glucose. Which of the following, if committed by a nurse, indicates an error?

• A. Specimen is collected after meals
• B. The nurse puts the clingiest tablet into a test tube
• C. She added 5 drops of urine and 10 drops of water
• D. If the color becomes orange or red, It is considered

Correct answer: C

Rationale: When conducting a Clinitest for testing urinary glucose levels, it is essential to add the correct amounts of urine and Clinitest reagent as instructed. Adding more water than urine could dilute the sample, leading to inaccurate test results. It's important to follow the correct ratio of drops specified in the instructions for an accurate reading.

5. Are M6 practical nurses utilized in field units with patient holding capabilities?

• A. Yes
• B. No
• C. -
• D. -

Correct answer: A

Rationale: Yes, M6 practical nurses are utilized in field units with patient holding capabilities. They play a crucial role in providing care and support in these settings. Choice B is incorrect as M6 practical nurses are indeed utilized in such field units, as stated in the extract. Choices C and D are not applicable as the correct answer is 'Yes.'

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