Nursing Elites

1. A male client reports the onset of numbness and tingling in his fingers and around his mouth. Which lab value is important for the nurse to review before contacting the health care provider?

• A. capillary glucose
• B. urine specific gravity
• C. Serum calcium
• D. white blood cell count

Correct answer: C

Rationale: The correct answer is C: Serum calcium. Numbness and tingling can be indicative of hypocalcemia, which can affect the nervous system. Reviewing serum calcium levels is crucial to address this potential issue. Options A, B, and D are not directly related to the symptoms described by the client and are not typically associated with numbness and tingling around the mouth and fingers. Capillary glucose levels are more relevant in assessing for diabetes or monitoring glucose control. Urine specific gravity is useful in evaluating hydration status. White blood cell count is typically checked to assess infection or immune response, which are not indicated by the client's symptoms of numbness and tingling.

2. Which action should the nurse include in the plan of care for a client receiving acyclovir (Zovirax) IV for treatment of herpes zoster (shingles)?

• A. Initiate cardiac telemetry monitoring
• B. Maintain continuous pulse oximetry
• C. Perform capillary glucose measurements
• D. Monitor serum creatinine levels

Correct answer: D

Rationale: The correct answer is D: Monitor serum creatinine levels. Acyclovir can lead to nephrotoxicity, making it essential to monitor kidney function through serum creatinine levels. While cardiac telemetry monitoring (choice A) and maintaining continuous pulse oximetry (choice B) are important in certain conditions, they are not directly related to acyclovir therapy for herpes zoster. Performing capillary glucose measurements (choice C) is not a priority when administering acyclovir for herpes zoster. Monitoring serum creatinine levels is crucial to detect any potential renal issues early, as the drug's nephrotoxic potential requires close monitoring of kidney function.

3. A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

• A. Ask the most experienced UAP on the team to partner with the newly hired UAP.
• B. Evaluate the newly hired UAP’s level of competency by observing the UAP deliver care.
• C. Review the UAP’s skills checklist and experience with the person who hired the UAP.
• D. Assign the newly hired UAP to clients who require the least complex level of care.

Correct answer: B

Rationale: Evaluating the newly hired UAP’s competency by observing them deliver care is the most effective intervention to ensure they can provide safe and effective care. This approach directly assesses the UAP's actual performance and allows for immediate feedback. Option A, asking the most experienced UAP to partner with the newly hired one, may not guarantee that the new UAP is competent. Option C, reviewing the UAP’s skills checklist and experience with the hiring person, does not provide a direct assessment of the UAP's current abilities. Option D, assigning the new UAP to less complex cases, does not address the need to evaluate their competency directly.

4. A client morning assessment includes bounding peripheral pulses, weight gain of 2 pounds, pitting ankle edema, and moist crackles bilaterally. Which intervention is most important for the nurse to include in this client’s plan of care?

• A. Restrict daily fluid intake to 1500 ml
• B. Weight the client every morning
• C. Maintain accurate intake and output
• D. Administer prescribed diuretic

Correct answer: D

Rationale: Administering a prescribed diuretic is the most important intervention in this scenario as the client is presenting signs of fluid overload and heart failure. Diuretics help reduce fluid retention in the body, alleviating symptoms like edema and crackles. Restricting fluid intake may be necessary in some cases, but in this acute situation, addressing the immediate fluid overload with a diuretic takes precedence. Weighing the client daily and maintaining accurate intake and output are important aspects of monitoring, but they do not directly address the urgent need to manage fluid overload.

5. The parents of a child who had surgical repair of a myelomeningocele are being taught how to change an occlusive dressing on the child’s back. Which statement by the parents indicates that they understand this procedure?

• A. When changing the dressing, the tape should be removed slowly to prevent trauma to the skin
• B. To prevent infection, the dressing should be kept dry to avoid excess moisture
• C. The skin incision should be kept moist to promote healing and prevent dryness
• D. The incision should be protected from fecal contamination by an intact dressing

Correct answer: D

Rationale: The correct answer is D because protecting the incision from fecal contamination is essential to prevent infection and promote healing in a child with a myelomeningocele. This is crucial as fecal matter can introduce harmful bacteria to the wound. Choice A is incorrect as removing the tape slowly to prevent trauma to the skin is a general guideline but not specific to preventing infection. Choice B is incorrect because keeping the dressing dry can lead to complications as the wound needs a moist environment to heal properly. Choice C is incorrect as keeping the skin incision moist may promote infection and delay healing, making it an incorrect statement for postoperative care.

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