Nursing Elites

1. A charge nurse is teaching a group of nurses about delegation. Which task should the nurse delegate to assistive personnel (AP)?

• A. Teaching a new mother how to breastfeed.
• B. Assisting a client with ambulation post-surgery.
• C. Helping with medication administration.
• D. Delegating IV medication administration.

Correct answer: B

Rationale: The correct answer is B. Assisting a client with ambulation post-surgery is a task that can be appropriately delegated to assistive personnel (AP) as it falls within their scope of duties. Teaching a new mother how to breastfeed and helping with medication administration involve assessments and critical thinking that are typically within the scope of licensed nursing staff, not AP. Delegating IV medication administration involves a higher level of skill and knowledge that should be performed by licensed nursing staff.

2. What is the first intervention for a patient experiencing anaphylactic shock?

• A. Administer epinephrine
• B. Administer oxygen
• C. Administer corticosteroids
• D. Administer antihistamines

Correct answer: A

Rationale: The correct answer is to administer epinephrine. Epinephrine is the first-line treatment for anaphylactic shock as it helps reverse the severe allergic reaction by constricting blood vessels, increasing heart rate, and opening airways for improved breathing. Oxygen (Choice B) can be administered after epinephrine to support oxygenation. Corticosteroids (Choice C) may be used to prevent a biphasic reaction but are not the initial intervention. Antihistamines (Choice D) can help with itching and hives but do not address the life-threatening symptoms of anaphylaxis.

3. A nurse is preparing to insert an indwelling urinary catheter for a client. Which of the following actions should the nurse take?

• A. Insert the catheter 7.5 cm (3 in) into the urethra.
• B. Insert the catheter until urine flow is established.
• C. Cleanse the catheter with sterile water before insertion.
• D. Insert the catheter 5 cm (2 in) into the urethra.

Correct answer: B

Rationale: The correct action for the nurse is to insert the catheter until urine flow is established. This helps ensure proper placement and reduces the risk of trauma. Choice A (7.5 cm) and Choice D (5 cm) provide specific measurements that may not be appropriate for all individuals as catheter insertion depth can vary. Choice C is incorrect as catheters should be cleansed with an appropriate solution such as sterile saline, not sterile water.

4. A client who has a new prescription for levothyroxine is receiving teaching from a nurse. Which statement by the client indicates an understanding of the teaching?

• A. I will need to take this medication for 3 months.
• B. I will take this medication with an antacid.
• C. I will avoid foods that contain iodine.
• D. I will take this medication in the morning before breakfast.

Correct answer: D

Rationale: The correct answer is D: "I will take this medication in the morning before breakfast." Levothyroxine should be taken in the morning before breakfast to improve absorption and effectiveness. Choice A is incorrect because the duration of levothyroxine therapy is usually long-term and not limited to 3 months. Choice B is incorrect because levothyroxine should not be taken with antacids as they may decrease its absorption. Choice C is incorrect because there is no need to avoid foods that contain iodine while taking levothyroxine.

5. A client in end-stage osteoporosis is reporting severe pain, with a respiratory rate of 14 per minute. Which of the following medications should the nurse expect to be the highest priority to administer to the client?

• A. Promethazine
• B. Hydromorphone
• C. Ketorolac
• D. Amitriptyline

Correct answer: B

Rationale: In a client with severe pain like the one described, the priority medication to administer is a potent analgesic like hydromorphone. Hydromorphone is a strong opioid pain medication that can effectively manage severe pain. Promethazine (Choice A) is an antiemetic and antihistamine, not a pain medication. Ketorolac (Choice C) is a nonsteroidal anti-inflammatory drug (NSAID) that is contraindicated in end-stage renal disease due to its potential to cause kidney damage. Amitriptyline (Choice D) is a tricyclic antidepressant used for conditions like depression and neuropathic pain, but it is not the first-line treatment for severe acute pain.

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